Health Assessment

Front 1

A medical examination differs from a comprehensive nursing examination
in that the medical examination focuses primarily on the client's
A. physiologic status.
B. holistic wellness status.
C. developmental history.
D. level of functioning.

Back 1

A. Physiological status

Front 2

The result of a nursing assessment is the
A. prescription of treatment.
B. documentation of the need for a referral.
C. client's physiologic status.
D. formulation of nursing diagnoses.

Back 2

D. formulation of nursing diagnoses.

Front 3

Although the assessment phase of the nursing process precedes the other
phases, the assessment phase is
A. continuous.
B. compieted on admission.
C. linear.
D. performed only by nurses.

Back 3

A. continuous.

Front 4

When a client first entres the hospital for an elective surgical procedure,
the nurse should perform an assessment termed
A. entry.
B. exploratory.
C. focused.
D. comprehensive.

Back 4

D. comprehensive.

Front 5

An ongoing or partial assessment of a client
A. focuses on a specific problem of the client.
B. includes a comprehensive overview of all body systems.
C. is usually performed by another health care worker.
D. includes a brief reassessment of the client's normal body system.

Back 5

D. includes a brief reassessment of the client's normal body system.

Front 6

To prepare for the assessment of a client visiting a neighborhood health
care clinic, the nurse should first
A. discuss the client's symptoms with other team members.
B. plan for potential laboratory procedures.
C. review the client's health care record.
D. determine potential health care resources.

Back 6

C. review the client's health care record.

Front 7

The nurse is preparing to meet a client in the clinic for the first time. After
reviewing the client's record, the nurse should
A. analyze data that have already been collected.
B. review any past collaborative problems.
C. avoid premature judgments about the client.
D. consult with the client's family members.

Back 7

C. avoid premature judgments about the client.

Front 8

Before beginning a comprehensive health assessment of an adult client,
the nurse should explain to the client that the purpose of the assessment
is to
A. arrive at conclusions about the client's health.
B. document any physical symptoms the client may have.
C. contribute to the medical diagnosis.
D. validate the data collected.

Back 8

A. arrive at conclusions about the client's health.

Front 9

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes
through the steps of analysis of data. After proposing possible nursing
diagnoses, the nurse should next
A. cluster the data collected.
B. draw inferences and identify problems.
C. document conclusions.
D. check for the presence of defining characteristics.

Back 9

D. check for the presence of defining characteristics.

Front 10

The depth and scope of nursing assessment has expanded significantly over
the past several decades primarily because of
A. the growing elderly population with chronic illness.
B. rapid advances in biomedical knowledge and technology.
C. an increase in the number of baccalaureate programs in nursing.
D. an increase in the number of nurse practitioners.

Back 10

B. rapid advances in biomedical knowledge and technology.

Front 11

When a client in considered in context, the term context refers to
A. . theoretic perspective.
B. setting, environment.
C. fanlily history.
D. chart content.

Back 11

B. setting, environment

Front 12

Which of the following statements about systems is not true?
A. A system is an interacting whole formed of many parts.
B. A system is more complex than the individual parts.
C. Systems interact with one another constantly.
D. All nursing conceptual frameworks consider the interacting systems
of client and context.

Back 12

D. All nursing conceptual frameworks consider the interacting systems
of client and context.

Front 13

Ethnocentrism is defined as
A. the belief that one's cultural values are superior to all others.
B. a tvorldview that each of us forms based on our own culture.
C. the basis of cultural competence.
D. a culture-hound syndrome found in many cultural groups.

Back 13

A. the belief that one's cultural values are superior to all others.

Front 14

Suzie is a 16-yearold daughter in the Hanes family. She is the youngest of five
children. She has had a series of illnesses and does not seem to be regaining
her strength. She likes school but is falling behind a bit. Her mother is very
attentive to her needs but does not seem overly concerned with the continuing
pattern of illness. Which of the followi~lgis most likely a Hanes family belief?
A. Fathers are not involved with their children.
B. Education is highly valued for sons and daughters.
C. Emotional stress from a work environl-[lent can cause both emotional
and physical illness.
D. Community is the context in which health care professionals care for
clients.

Back 14

D. Community is the context in which health care professionals care for
clients.

Front 15

Which of the following is the best reason for the nurse to assess the client's
community?
A. There is an interaction of culture, family, and envrironmental systems
with the client's emotional and physical systems affecting the client's health status.
B. Pollution from an unhealthy community can affect the client's physical health.
C. Emotional stress from a work environment can cause both emotional and physical illness.
D. Community is the context in which health care professionals care for clients.

Back 15

A. There is an interaction of culture, family, and envrironmental systems
with the client's emotional and physical systems affecting the client's health status.

Front 16

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's
A. perception of pain.
B. height.
C. weight.
D. temperature.

Back 16

A. perception of pain.

Front 17

During an interview with an adult client, the nurse can keep the interview
from going off course by
A. using open-ended questions.
8. rephrasing the client's statements.
C. inferring information.
D. using closed-cndcd questions.

Back 17

D. using closed-cndcd questions.

Front 18

The nurse has interviewed a Hispanic client with li~nitedE nglish skills for
the first time. The nurse observes that the client is reluctant to reveal
personal information and believes in a hot-cold syndro~neo f disease
causation. The nurse should
A. acknowledge the client's cultural differences.
B. request a family member to interpret for the client.
C. use slang terms to identify certain body parts.
D. remain in a standing position during the interview.

Back 18

A. acknowledge the client's cultural differences.

Front 19

For a nurse ro be therapeutic with clients when dealing with sensitive
issues such as terminal illness or sexuality, the nurse should have
A. advanced preparation in this area.
B. experience in dealing with these types of clients.
C. knowledge of his or her own thoughts and feelings about these issues.
D. personal experiences with death, dying, and sexuality.

Back 19

C. knowledge of his or her own thoughts and feelings about these issues.

Front 20

The nurse is interviewing a client in the clinic for the first time. The client
appears to have a very limited vocabulary. 'The nurse should plan to
A. use very basic lay terminology.
B. have a family member present during the interview.
C. use standard medical terminology.
D. show the client pictures of different symptoms, such as the "Faces Pain
Chart."

Back 20

A. use very basic lay terminology.

Front 21

The nurse is interviewing a client in the clinic for the first time. When the
client tells the nurse that he smokes "about two packs of cigarettes a day,"
the nurse should
A. look at the client with a frown.
B. tell the client that he is spending a lot of money foolishly.
C. provide the client with a list of dangers associated with smoking.
D. encourage the client to quit smoking.

Back 21

D. encourage the client to quit smoking.

Front 22

During the client interview, the nurse uses nonverbal expressions
appropriately when the nurse
A. avoids excessive eye contact with the client.
B. remains expressionless throughout the interview.
C. uses touch in a friendly manner to establish rapport.
D. displays mental distancing during the interview.

Back 22

A. avoids excessive eye contact with the client.

Front 23

During the interview of an adult client, the nurse should
A. use leading questions for valid responses.
B. provide the client with information as questions arise.
C. read each question carefully from the history form.
D. complete the interview as quickly as possible.

Back 23

B. provide the client with information as questions arise.

Front 24

While interviewing a client for the first time, the nurse is using a
standardized nursing history form. The nurse should
A. maintain eye contact while asking the questions from the form.
B. read the questions verbatim from the form.
C. ask the client to complete the form.
D. ask leading questions throughout the interview.

Back 24

A. maintain eye contact while asking the questions from the form.

Front 25

The nurse is interviewing a 73-year-old client for the first time. The nurse
should first
A. assess the client's hearing acuity.
B. establish rapport with the client.
C. obtain biographic data.
D. use medical terminology appropriately.

Back 25

A. assess the client's hearing acuity.

Front 26

During an interview with an adult client for the first time, the nurse can
clarify the client's statements by
A. offering a "laundry list" of descriptors.
B. rephrasing the client's statements.
C. repeating verbatim what the client has said.
D. inferring what the client's statements mean.

Back 26

B. rephrasing the client's statements.

Front 27

During the interview between a nurse and a client, the nurse and the client
collaborate to identify problems and goals. This occurs during the phase
of the interview termed
A. introductory.
B. ongoing.
C. working.
D. closure.

Back 27

C. working.

Front 28

The nurse is preparing to interview an adult client for the first time. The
nurse observes that the client appears very anxious. The nurse should
A. allow the client time to calm down.
B. avoid discussing sensitive issues.
C. set time limits with the client.
D. explain the role and purpose of the nurse.

Back 28

D. explain the role and purpose of the nurse.

Front 29

The nurse is beginning a health history interview with an adult client who
expresses anger at the nurse. The best approach for dealing with an angry
client is for the nurse to
A. allow the client to ventilate his or her feelings.
B. offer reasons why the client shouldn't feel angry.
C. provide structure during the interview.
D. refer the client to a different health care provider.

Back 29

A. allow the client to ventilate his or her feelings.

Front 30

The nurse is planning to interview a client who is being treated for
depression. When the nurse enters the examination room, the client is
sitting on the table with shoulders slumped. The nurse should plan to
approach this client by
A. providing the client with simple explanations.
B. offering to hold the client's hand.
C. using a highly structured interview process.
D. expressing interest in a neutral manner.

Back 30

D. expressing interest in a neutral manner.

Front 31

The nurse is planning to interview a client who has demonstrated
manipulative behaviors during past clinic visits. During the interview
process, the nurse should plan to
A. give the client rules with which he must agree to comply.
B. provide structure and set limits with the client.
C. tell the client that the nurse is aware of his past behaviors.
D. approach the client in an authoritative manner.

Back 31

B. provide structure and set limits with the client.

Front 32

During a client interview, the nurse asks questions about the client's
past health history. The primary purpose of asking about past health
problems is to
A. determine whether genetic conditions are present.
B. summarize the family's health problems.
C. evaluate how the client's current symptoms affect lifestyle.
D. identifv risk factors to the client and his or her significant others

Back 32

D. identifv risk factors to the client and his or her significant others

Front 33

While interviewing an adult client about her nutrition habits, the nurse should
A. ask the client for a 3-day recall of food intake.
B. review the food pyramid with the client.
C. ask the client about limitations to activity.
D. encourage the client to drink three to four glasses of water daily.

Back 33

B. review the food pyramid with the client.

Front 34

While interviewing an adult client about the client's stress levels and coping responses, an
appropriate question by the nurse is
A. "Do you feel stress at work?"
B. "How often do you feel stressed?"
C. "Is stress a problem in your life?"
D. "How do you manage your stress?"

Back 34

D. "How do you manage your stress?"

Front 35

Before beginning a physical assessment of a client, the nurse should first
A. wash both hands with soap and water.
B. determine whether the client is anxious.
C. ask the client to remove all clothing.
D. request a iamily member to be present.

Back 35

A. wash both hands with soap and water.

Front 36

To alleviate a client's anxiety during a comprehensive assessment, the
nurse should
A. begin with intrusive procedures first to get them completed quickly.
B. explain each procedure being performed and the reason for the
procedure.
C. remain in the examination room while the client changes into a gown.
D. ask the client to sign a consent for the physical examination.

Back 36

B. explain each procedure being performed and the reason for the
procedure.

Front 37

While performing a physical examination on an older adult, the nurse should plan to
A. complete the examination as quickly as possible.
B. ask the client to change positions frequently.
C. provide only minimal teaching related to health care.
D. use minimal position changes during the examination.

Back 37

D. use minimal position changes during the examination.

Front 38

During a comprehensive assessment, the primary technique used by the
nurse throughout the examination is
A. palpation.
B. percussion.
C. auscultation.
D. inspection.

Back 38

D. inspection.

Front 39

While examining a client, the nurse plans to palpate temperature of the
skin by using the
A. fingertips of the hand.
B. ulnar surface of the hand.
C. dorsal surface of the hand.
D. palmar surface of the hand.

Back 39

C. dorsal surface of the hand

Front 40

During palpation of the client's organs, the nurse palpates the spleen
by applying pressure between 2.5 and 5 centimeters. The nurse
is performing
A. light palpation.
B. moderate palpation.
C. deep palpation.
D. very deep palpation.

Back 40

C. deep palpation.

Front 41

While performing a physical examination on a adult client, the nurse
can detect the density of an underlying structure by using
A, inspection.
B. palpation.
C. Doppler magnification.
D. percussion.

Back 41

D. percussion.

Front 42

When the nurse places one hand flat on the body surface and uses the fist
of the other hand to strike the back of the hand flat on the body surface, the nurse is using
A. firm percussion.
B. direct percussion.
C. indirect percussion.
D. blunt percussion

Back 42

D. blunt percussion

Front 43

An adult client visits the clinic and tells the nurse that she suspects she has a urinary tract infection. To detect tenderness over the client's kidneys, the
nurse should instruct the client that the nurse will be performing
A. moderate palpation.
B. deep palpation.
C. indirect percussion.
D. blunt percussion.

Back 43

D. blunt percussion.

Front 44

The most commonly used method of percussion is
A. direct percussion.
B. mild percussion.
C. indirect percussion.
D. blunt percussion.

Back 44

C. indirect percussion.

Front 45

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit
A. hyperresonance.
B. tympany.
C. dullness.
D. flatness.

Back 45

A. hyperresonance.

Front 46

While percussing an adult client during a physical examination, the nurse
can expect to hear flatness over the client's
A. lungs.
B. bone.
C. liver.
D. abdomen.

Back 46

B. bone.

Front 47

During a comprehensive assessment of an adult client, the nurse can best
hear high-pitched sounds by using a stethoscope with a
A. 1-inch bell.
B. 1 1/2-inch diaphragm.
C. 15-inch flexible tubing.
D. 1-inch diaphragm.

Back 47

B. 1 1/2-inch diaphragm.

Front 48

If the nurse makes an error while documenting findings on a client's
record, the nurse should
A. erase the error and make the correction.
B. obliterate the error and make the correction.
C. draw a line through the error and have it witnessed.
D. draw a line through the error, writing "error" and initialing.

Back 48

D. draw a line through the error, writing "error" and initialing.

Front 49

The nurse is preparing to document assessment findings in a client's
record. The nurse should
A. write in complete sentences with few abbreviations.
B. avoid slang terms or labels unless they are direct quotes.
C. record how the data were collected.
D. use the term normal for normal findings.

Back 49

B. avoid slang terms or labels unless they are direct quotes.

Front 50

The nurse has assessed the breath sounds of an adult client. The best way
for the nurse to document these findings on a client is to write
A. "Bilateral lung sounds clear."
B. "The client's lung sounds were clear on both sides."
C. "Client's lung sounds were auscultated with stethoscope and were
clear on both sides."
D. "After listening to client's lung sounds, both lungs appeared clear."

Back 50

A. "Bilateral lung sounds clear."

Front 51

An example of an objective finding in an adult client is
A. a client's symptom of pain.
B. family history data.
C. genetic disorders.
D. vital signs.

Back 51

D. vital signs.

Front 52

While recording the subjective data of an adult client who complains of
pain in his lower back, the nurse should include the location of the pain
and the
A. cause of the pain.
B. client's caregiver.
C. client's occupation.
D. pain relief measures.

Back 52

D. pain relief measures.

Front 53

One disadvantage of the open-ended assessment form is that it
A. doesn't allow for individualization.
B. asks standardized questions.
C. requires a lot of time to complete.
D. doesn't provide a total picture of the client.

Back 53

C. requires a lot of time to complete.

Front 54

The nurse is recording admission data for an adult client using a cued or
checklist type of assessment form. This type of assessment form
A. prevents missed questions during data collection.
B. covers all the data that a client may provide.
C. clusters the assessment data with nursing diagnoses.
D. establishes comparability of data across populations.

Back 54

A. prevents missed questions during data collection.

Front 55

One advantage for an institution to use an integrated cued/cllecklist type
of assessment data form is that it
A. allows a comprehensive and thorough picture of the client's
symptoms.
B. may be easily used by different levels of caregivers, which enhances communication.
C. provides for easy and rapid documentation across clinical settings and
populations.
D. includes the 11 health care patterns in an easily readable format.

Back 55

B. may be easily used by different levels of caregivers, which enhances communication.

Front 56

An assessment form commonly used in long-term care facilities is the
nursing minimum data set. One primary advantage to this type of
assessment form is that it
A. establishes comparability of nursing data across clinical
populations.
B. clusters all the nursing and medical diagnoses in one place.
C. allows for individualization for each client in the health care
setting.
D. uses a flow chart format for easy documentation of objective data.

Back 56

A. establishes comparability of nursing data across clinical
populations.

Front 57

In some health care settings, the institution uses an assessment form that
assesses only one part of a client. These types of forms are termed
A. progressive.
B. specific.
C. checklist.
D. focused.

Back 57

D. focused.

Front 58

The nurse is planning to assess a newly admitted adult client. While gathering data ft-om the client, the nurse should
A. validate all data before documentation of the data.
B. document the data after the entire exa~nination process.
C. record the nurse's understanding of the client's problem.
D. use medical terms that are comn~onlyu sed in health care settings.

Back 58

A. validate all data before documentation of the data.

Front 59

One characteristic of a nurse who is a critical thinker is the ability to
A. form an opinion quickly.
B. offer advice to clients
C. be right most of the time.
D. validate information and judgments.

Back 59

D. validate information and judgments.

Front 60

Before the nurse analyzes the data collected, the nurse should
A. determine collaborative problems with the health care team.
B. group the data into clusters or groups of problems.
C. generate possible hypotheses for the client's problems.
D. perform the steps of the assessment process accurately.

Back 60

D. perform the steps of the assessment process accurately.

Front 61

The nurse is caring for an adult client who tells the nurse "For weeks now,
I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is
A. Fatigue related to excessive noise levels as manifested by client's
statements of chronic fatigue.
B. Sleep deprivation related to noisy neighborhood and inability to sleep.
C. Chronic fatigue syndrome related to excessive levels of noise in neighborhood.
D. Readiness for enhanced sleep related to control of noise level in the home.

Back 61

A. Fatigue related to excessive noise levels as manifested by client's
statements of chronic fatigue.

Front 62

A common error for beginning nurses who are formulating nursing
diagnoses during data analysis is to
A. formulate too many nursing diagnoses for the client and family.
B. include too much data about the client in the history,
C. obtain an insufficient number of cues and cluster patterns.
D. quickly make a diagnosis without hypothesizing several diagnoses.

Back 62

D. quickly make a diagnosis without hypothesizing several diagnoses.

Front 63

The nurse is preparing to assess an adult client in the clinic. The nurse observes
that the client is wearing lightweight clothing although the temperature is below
freezing outside. The nurse anticipates that the client may be
A. abusing drugs.
B. a victim of abuse.
C. lacking adequate finances.
D. anxious.

Back 63

C. lacking adequate finances.

Front 64

An elderly client is seen by the nurse in the neighborhood clinic. The nurse
observes that the client is dressed in several layers of clothing, although the
temperature is warm outside. The nurse suspects that the client's cold
intolerance is a result of
A. decreased body metabolism.
B. neurologic deficits.
C. recent surgery.
D. pancreatic disease.

Back 64

A. decreased body metabolism.

Front 65

Which of the following is part of a Mental Status Exam?
A. Eliciting reflexes.
B. Evaluating level of consciousness.
C. Evaluating pain sensations.
D. Assessing cranial nerves.

Back 65

B. Evaluating level of consciousness.

Front 66

The nurse is assessing an elderly postsurgical client in the home. To begin
the physical examination, the nurse should first assess the client's
A. height and weight.
B. ability to swallow.
C. vital signs.
D. gait.

Back 66

C. vital signs.

Front 67

While caring for an 80-year-old client In his home, the nurse determines
that the client's temperature is 963°F. The nurse determines that the client
is most likely exhibiting
A. normal changes that occur with the aging process.
B. hypothermia that occurs before an infectious process.
C. a metabolic disorder resulting in circulatory changes.
D. an immune disorder resulting in low platelet count.

Back 67

A. normal changes that occur with the aging process.

Front 68

The nurse is preparing to assess the respirations of an alert adult client. The
nurse should
A. explain to the client that he or she will be counting the client's
respirations.
B. observe for equal bilateral chest expansion of 1 to 2 inches.
C. count for 15 seconds and multiply the number by four to obtain the
rate.
D. ask the client to lie in a supine position, which makes counting the
respirations easier.

Back 68

B. observe for equal bilateral chest expansion of 1 to 2 inches.

Front 69

W hile assessing an older adult client's respirations, the nurse can anticipate
that the respiratory pattern may exhibit a
A. shorter inspiratory phase.
B. longer inspiratory phase.
C. shorter expiratory phase.
D. longer expiratory phase.

Back 69

A. shorter inspiratory phase

Front 70

The nurse is caring for a client who is having nothing by mouth (NPO) on
the first postoperative day. The client's blood pressure was 120/80 mm Hg
approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should
ask the client which of the following questions?
A. "Are you taking any medications for hypertension?"
B. "Do you have enough blankets to stay warm?"
C. "Are you having pain from your surgery?"
D. "What is your typical blood pressure reading?"

Back 70

C. "Are you having pain from your surgery?"

Front 71

A normal pulse pressure range for an adult client is typically
A. 20 to 40 mm Hg.
B. 30 to 50 mm Hg.
C. 40 to 60 mm Hg.
D. 60 to 80 mm Hg.

Back 71

B. 30 to 50 mm Hg.

Front 72

When assessing the client for pain, the nurse should
A. doubt the client when helshe describes the pain.
B. assess for underlying causes of pain, then believe the client.
C. believe the client when he/she clainls to be in pain.
D. assess for the presence of physiologic indicators (such as diaphoresis, tachycardia, etc.), then believe the client.

Back 72

C. believe the client when he/she clainls to be in pain.

Front 73

Acute pain can be differentiated from chronic pain because
A. acute pain always scores more on the visual analog scale than chronic
pain.
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.
C. acute pain is not treated and left to subside on its own, whereas chronic
pain is referred for treatment.
D. acute pain occurs only in persons aged less than 45 years, whereas chronic pain occurs in persons aged 46 or above

Back 73

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.

Front 74

One of the body's normal physiologic responses to pain is
A. hypotension.
B. pulse rate below 50/min.
C. diaphoresis.
D. hypoglycemia.

Back 74

C. diaphoresis.

Front 75

A fter assessing a client in pain, the nurse
A. documents the exact description given by the client.
B. chooses from the list of pain descriptors what best reflects the client's description.
C. asks the family to describe how they view the client's pain.
D. documents how helshe best sees the clienr's pain.

Back 75

A. documents the exact description given by the client.

Front 76

The nurse is caring for an adult female client whose body mass index is 38.7. The nurse should
instruct the client that she is at greater risk for:
A. heart attack.
B. osteoporosis.
C. rheumatoid arthritis.
D. stomach cancer.

Back 76

A. heart attack.

Front 77

Waist circumference guidelines may not be accurate for adult clients who are shorter than five feet in
height. This restriction is also a concern for which other anthropometric measurement?
A. Ideal weight
B. Mid-arm circumference
C. Body mass index
D. Triceps skin-fold measurements

Back 77

C. Body mass index

Front 78

Based only on anthropometric measurements, which set of clients listed
below is at the greatest risk for diabetes and cardiovascular disease?
A. Clients with a body mass index of 23
B. Females with 35 inches or greater waist circumference
C. Males with 35 inches or greater waist circumference
D. Clients with a body mass index of 20

Back 78

B. Females with 35 inches or greater waist circumference

Front 79

What is the most common measurement used to determine abdominal
visceral fat?
A. Waist circumference
B. Body mass index (BMI)
C. Subcutaneous fat determination
D. Triceps skin-fold thickness

Back 79

A. Waist circumference

Front 80

Because body mass index (BMI) is calculated using only height and weight,
the nurse knows that inaccurate findings would most likely occur in a
client
A. with diabetes.
B. who is six feet tall.
C. with osteoarthritis.
D. who is a bodybuilder.

Back 80

D. who is a bodybuilder.

Front 81

The nurse documents that a 45-yearold male is 5 feet 10 inches tall and
weighs 215 pounds. He tells the nurse that he "has a good appetite, but
doesn't get much exercise because of his busy work schedule." An
appropriate NANDA nursing diagnosis for this client is
A. Normal body nutrition related to healthy eating patterns and good
appetite.
B. Altered nutrition, more than body requirements related to intake greater than calories expended.
C. Risk for altered nutrition, more than body requirements related to lack a routine exercise.
D. Obesity related to lack of exercise.

Back 81

B. Altered nutrition, more than body requirements related to intake greater than calories expended.

Front 82

The nurse is preparing to measure the triceps skin-fold of an adult client.
The nurse should
A. ask the client to assume a sitting position.
B. measure the triceps skin-fold in the dominant arm.
C. repeat the procedure three times and average the measurements.
D. pull the skin toward the muscle mass of the arm.

Back 82

C. repeat the procedure three times and average the measurements.

Front 83

During a thorough spiritual assessment, the nurse understands that the
questions asked are designed to
A. encourage the client to explore other religions.
B. cause the client to question long-held beliefs.
C. determine if the client and nurse have similar beliefs.
D. reveal beliefs that might affect client care.

Back 83

D. reveal beliefs that might affect client care.

Front 84

Loss of connection with one's spiritual support most often leads to
A. a new-found sense of liberation.
B. spiritual distress.
C. improved sense of health and well-being.
D. increased adherence to religious practices.

Back 84

B. spiritual distress.

Front 85

Knowledge of the client's beliefs in the cause of illness can be useful to the
nurse in order to
A. encourage new beliefs.
B. dispel religious teachings if they conflict with the nurse's belief system.
C. promote harmony between health and spirituality.
D. raise doubt and point out flaws in one's faith.

Back 85

C. promote harmony between health and spirituality.

Front 86

Because the nurse realizes that spirituality varies, information gained will
assist the nurse in
A. individualizing interventions to meet specific needs.
B. diagnosing the client with spiritual distress.
C. teaching strict adherence to rituals and practices to improve outcomes.
D. providing an overview of widely held beliefs from the major religions

Back 86

A. individualizing interventions to meet specific needs.

Front 87

Connecting the skin to underlying structures islare the
A. papillae.
B. sebaceous glands.
C. dermis layer.
D. subcutaneous tissue.

Back 87

D. subcutaneous tissue.

Front 88

The skin plays a vital role in temperature maintenance, fluid and electrolyte
balance, and synthesis of vitamin
A. A.
B. B,"",.
C. C.
D. D.

Back 88

D. D.

Front 89

The only layer of the skin that undergoes cell division is the
A. innermost layer of the epidermis.
B. outermost layer of the epidermis.
C. innermost layer of the dermis.
D. outermost layer of the dermis.

Back 89

A. innermost layer of the epidermis.

Front 90

A client's skin color depends on melanin and carotene contained in the
skin, and the
A. client's genetic background.
B. volume of blood circulating in the dermis.
C. number of lymph vessels near the dermis.
D. vascularity of the apocrine glands.

Back 90

B. volume of blood circulating in the dermis.

Front 91

Hair follicles, sebaceous glands, and sweat glands originate from the
A. epidermis.
B. eccrine glands.
C. keratinized tissue.
D. dermis.

Back 91

D. dermis.

Front 92

The apocrine glands are dormant until puberty and are concentrated in the
axillae, the perineum, and the
A. areola of the breast.
B. entire skin surface.
C. soles of the feet.
D. adipose tissue.

Back 92

A. areola of the breast.

Front 93

Short, pale, and fine hair that is present over much of the body is termed
A. vellus.
B. dermal.
C. lanugo.
D. terminal.

Back 93

A. vellus.

Front 94

A primary function of hair in the nose and eyelashes is to serve as a
A. response to cold.
B. filter for dust.
C. pigment producer.
D. response to fright.

Back 94

B. filter for dust.

Front 95

The nails, located on the distal phalanges of the fingers and toes, are
composed of
A. ectodermal cells.
B. endodermal cells.
C. keratinized epidermal cells.
D. stratum cells.

Back 95

C. keratinized epidermal cells

Front 96

An adult female client visits the clinic for the first time. The client has
many bruises around her neck and face, and she tells the nurse the bruises
are the "result of an accident." The nurse suspects that the client may be
experiencing
A. leukemia.
B. diabetes mellitus.
C. melanoma.
D. domestic abuse.

Back 96

D. domestic abuse

Front 97

An adult male client visits the outpatient center and tells the nurse that he
has been experiencing patchy hair loss. The nurse should further assess
the client for
A. symptoms of stress.
B. recent radiation therapy.
C. pigmentation irregularities.
D. allergies to certain foods.

Back 97

A. symptoms of stress.

Front 98

The nurse is instructing a group of high school students about risk factors
associated with various skin cancers. The nurse should instruct the group
that
A. melanoma skin cancers are the most common type of cancers.
B. African Americans are the least susceptible to skin cancers.
C. usually there are precursor lesions for basal cell carcinomas.
D. squamous cell carcinomas are most conlmon on body sites with heavy sun exposure.

Back 98

D. squamous cell carcinomas are most conlmon on body sites with heavy sun exposure.

Front 99

Squarnous cell carcinoma is associated with
A. overall amount of sun exposure.
B. intermittent exposure to ultraviolet rays.
C. precursor lesions.
D. an increase in the rates of melanoma.

Back 99

A. overall amount of sun exposure.

Front 100

The nurse is assessing an African-American client's skin. After the
assessment, the nurse should instruct the client that African-American
persons are more susceptible to
A. skin cancers than persons of European origin.
B. melanomas if they reside in areas without ozone depletion.
C. chronic discoid lupus erythematosus.
D. genetic predisposition to melanomas.

Back 100

C. chronic discoid lupus erythematosus.

Front 101

A 20-year-old client visits the outpatient center and tells the nurse that he
has been experiencing sudden generalized hair loss. After determining that
the client has not received radiation or chemotherapy, the nurse should
further assess the client for signs and symptoms of
A. hypothyroidism.
B. hyperthyroidism.
C. infectious conditions.
D. hypoparathyroidism.

Back 101

A. hypothyroidism.

Front 102

A client visits the clinic for a routine physical examination. The nurse
prepares to assess the client's skin. The nurse asks the client if there is a
family history of skin cancer and should explain to the client that there is
a genetic component with skin cancer, especially
A. basal cell carcinoma.
B. actinic keratoses.
C. squamous cell carcinoma.
D. malignant melanoma.

Back 102

D. malignant melanoma.

Front 103

A female client visits the clinic and complains to the nurse that her skin
feels "dry." The nurse should instruct the client that skin elasticity is
related to adequate
A. calcium.
B. vitamin D.
C. carbohydrates.
D. fluid intake.

Back 103

D. fluid intake.

Front 104

An adult white client visits the clinic for the first time. During assessment
of the client's skin, the nurse should assess for central cyanosis by
observing the client's
A. nailbeds.
B. oral mucosa.
C. sclera.
D. palms.

Back 104

B. oral mucosa.

Front 105

To assess for anemia in a dark-skinned client, the nurse should observe
the client's skin for a color that appears
A. greenish.
B. ashen.
C. bluish.
D. olive.

Back 105

B. ashen.

Front 106

Th e nurse is assessing a dark-skinned client who has been transported to
the emergency room by ambulance. When the nurse observes that the
client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse
should document the presence of
A. a great degree of cyanosis.
B. a mild degree of cyanosis.
C. lupus erythematosus.
D. hyperthyroidism.

Back 106

A. a great degree of cyanosis.

Front 107

A dark-skinned client visits the clinic because he "hasn't been feeling
well." To assess the client's skin for jaundice, the nurse should inspect the
client's
A. abdomen.
B. arms.
C. legs.
D. sclera.

Back 107

D. sclera.

Front 108

While assessing the skin of an older adult client, the nurse observes that
the client has small yellowish brown patches on her hands. The nurse
should instruct the client that these spots are
A. signs of an infectious process.
B. caused by aging of the skin in older adults.
C. precancerous lesions.
D. signs of dermatitis.

Back 108

B. caused by aging of the skin in older adults.

Front 109

While assessing an adult client's feet for fungal disease using a \Vood's light,
the nurse documents the presence of a fungus when the fluorescence is
A. blue.
B. red.
C. yellow.
D. purple.

Back 109

A. blue.

Front 110

The nurse assesses an older adult bedridden client in her home. While
assessing the client's buttocks, the nurse observes that a small area of the
skin is broken and resembles an erosion. The nurse should document the
client's pressure ulcer as
A. stage I.
B. stage II.
C. stage III.
D. stage IV.

Back 110

B. stage II.

Front 111

To assess an adult client's skin turgor, the nurse should
A. press down on the skin of the feet.
B. use the dorsal surfaces of the hands on the client's arms.
C. use the fingerpads to palpate the skin at the sternum.
D. use two fingers to pinch the skin under the clavicle.

Back 111

D. use two fingers to pinch the skin under the clavicle.

Front 112

While assessing the nails of an adult client, the nurse observes Beau's lines.
The norsq should ask the client if he has had
A. chemotherapy.
B. radiation.
C. a recent illness.
D. steroid therapy.

Back 112

C. a recent illness.

Front 113

While assessing the nails of an older adult, the nurse observes early
clubbing. The nurse should further evaluate the client for signs and
synlptotns of
A. hypoxia.
B. trauma.
C. anemia.
D. infection.

Back 113

A. hypoxia.

Front 114

While assessing an adult client, the nurse observes freckles 011 the client's
face. The nurse should document the presence of
A. macules.
B. papules.
C. plaques.
D. bulla.

Back 114

A. macules.

Front 115

While assessing an adult client, the nurse observes an elevated, palpable,
solid mass with a circumscribed border that measures 1. centimeter. The
nurse documents this as a
A. plaque.
B. macule.
C. papule.
D. patch.

Back 115

A. plaque.

Front 116

The nurse is preparing to examine the skin of an adult client with a
diagnosis of herpes simplex. The nurse plans to measure the client's
syniptomatic lesions and measure the size of the client's
A. nodules.
B. bullae.
C. vesicles.
D. wheals.

Back 116

C. vesicles.

Front 117

An adult male client visits the clinic and tells the nurse that he believes he
has athlete's foot. The nurse observes that the client has linear cracks in
the skin on both feet. The nurse should document the presence of
A. ulcers.
B. erosion.
C. scales.
D. fissures.

Back 117

D. fissures.

Front 118

An African-American female client visits the clinic. She tells the nurse that
she had her ears pierced several weeks ago, and an elevated, irregular,
reddened mass has now developed at the earlobe. The nurse should
document a
A. cyst.
B. lichenification.
C. bulla.
D. keloid.

Back 118

D. keloid.

Front 119

A client who is an active outdoor swimmer recently received a diagnosis
of discoid systemic lupus erythematosus. The client visits the clinic for a
routine examination and tells the nurse that she continues to swim in the
sunlight three times per week. She has accepted her patchy hair loss and
wears a wig on occasion. A priority nursing diagnosis for the client is
A. Ineffective individual coping related to changes in appearance.
B. Anxiety related to loss of outdoor activities and altered skin
appearance.
C. Dry flaking skin and dull dry hair as a result of disease.
D. Risk for ineffective health maintenance related to deficient knowledge
of effects of sunlight on skin lesions.

Back 119

D. Risk for ineffective health maintenance related to deficient knowledge
of effects of sunlight on skin lesions.

Front 120

The nurse assesses an adult client's head and neck. While examining the
carotid arteries, the nurse assesses each artery iridividually in order to
prevent a
A. reduction of the blood supply to the brain.
B. rapid rise in the client's pulse rate.
C. premature ventricular heart sound.
D. decreased pulse pressure.

Back 120

A. reduction of the blood supply to the brain.

Front 121

A client visits the outpatient center with a complaint of sudden head and
neck pain and stiffness. The client's oral temperature is 100°F. The nurse
suspects the client is experiencing symptoms of
A. migraine headache.
B. meningeal irritation.
C. trigeminal neuralgia.
D. otitis media.

Back 121

B. meningeal irritation.

Front 122

While assessing the head and neck of an adult client, the client tells the
nurse she has been experiencing sharp shoot~ngfa cial pains that last from
10 to 20 seconds but are occurring more frequently. The nurse should
refer the client for possible
A. cancerous lesions.
B. arterial occlusion.
C. inner ear disease.
D. trigeminal neuralgia.

Back 122

D. trigeminal neuralgia.

Front 123

A female client visits the clinic and tells the nurse that she frequently
experiences severe recurring headaches that sometimes last for several days
and are accompanied by nausea and vomiting. The nurse determines that
the type of headache the client is describing is a
A. tnigraine headache.
B. cluster headache.
C. tension headache.
D. tumor-related headache.

Back 123

A. tnigraine headache.

Front 124

An adult client visits the clinic and tells the nurse that she has had
headaches recently that are intense and stabbing and often occur in the
late evening. The nurse should document the presence of
A. cluster headaches.
B. migraine headaches.
C. tension headaches.
D. tumor-related headaches.

Back 124

A. cluster headaches.

Front 125

A client visits the clinic and tells the nurse that he is depressed because of
a recent job loss. He complains of dull, aching, tight, and diffuse
headaches that have lasted for several days. The nurse should document
the client's
A. cluster headaches.
B. tumor-related headaches.
C. migraine headaches.
D. tension headaches.

Back 125

D. tension headaches.

Front 126

An older client visits the clinic accompanied by his daughter The
daughter tells the nurse that her father has been experiencing severe
headaches that usually begin in the morning and become worse when he
coughs. The client tells the nurse that he feels dizzy when he has the
headaches. The nurse refers the client for further evaluation because these
symptoms are characteristic of a
A. migraine headache.
B. cluster headache.
C. tension headache.
D. tumor-related headache.

Back 126

D. tumor-related headache.

Front 127

The nurse is preparing to perform a head and neck assesslnent of an adult
client who has immigrated to the United States from Cambodia. The
nurse should first
A. explain to the client why the assessment is necessary.
B. ask the client if touching the head is permissible.
C. determine whether the client desires a family member present.
D. examine the lymph nodes of the neck before examining the head.

Back 127

B. ask the client if touching the head is permissible.

Front 128

While assessing an adult client's skull, the nurse observes that the client's skull
and facial bones are larger and thicker than usual. The nurse should assess
the client for
A. parotid gland enlargement.
B. acromegaly.
C. Paget's disease.
D. Cushing's syndrome.

Back 128

B. acromegaly.

Front 129

While assessing an adult client's skull, the nurse observes that the client's
skull bones are acorn shaped and enlarged. The nurse should refer the
client to a physician for possible
A. Cushing's syndrome.
B. scleroderma.
C. Paget's disease.
D. Parkinson's disease.

Back 129

C. Paget's disease.

Front 130

While assessing an adult client's head and neck, the nurse observes
asymmetry in front of the client's earlobes. The nurse refers the client to
the physician because the nurse suspects the client is most likely
experiencing alan
A. enlarged thyroid.
B. lymph node abscess.
C. neurologic disorder.
D. parotid gland enlargement.

Back 130

D. parotid gland enlargement.

Front 131

The nurse is preparing to assess the neck of an adult client. To inspect
movement of the client's thyroid gland, the nurse should ask the client to
A. inhale deeply.
B. swallow a small sip of water.
C. cough deeply.
D. flex the neck to each side.

Back 131

B. swallow a small sip of water.

Front 132

While assessing an older adult client's neck, the nurse observes that the
client's trachea is pulled to the left side. The nurse should
A. ask the client to flex his neck to the left side.
B. observe whether the client has difficulty swallowing water.
C. refer the client to a physician for further evaluation.
D. palpate the cricoid cartilage for smoothness.

Back 132

C. refer the client to a physician for further evaluation.

Front 133

The nurse is planning to assess an adult client's thyroid gland. The nurse
should plan to
A. ask the client to raise the chin.
B. approach the client posteriorly.
C. turn the client's neck slightly backward.
D. place the fingers above the cricoid cartilage.

Back 133

B. approach the client posteriorly

Front 134

The nurse is preparing to assess the lymph nodes of an adult client. The
nurse should instruct the client to
A. lie in a supine position.
B. lie in a side-lying position.
C. stand upright in front of the nurse.
D. sit in an upright position.

Back 134

D. sit in an upright position.

Front 135

K female client visits the clinic and tells the nurse that she wants to "stay
healthy." The nurse observes that the client has diffuse neck enlargement,
is perspiring, and is quite fidgety. The client tells the nurse that she is
"hungry all the time, but I have lost weight." h priority nursing diagnosis
for the client is
A. imbalanced nutrition: less than body requirements related to energy
level.
B. ineffective health maintenance related to increased metabolism and
hunger.
C. health-seeking behaviors related to verbalization of wanting to stay healthy.
D. thyroid dysfunction related to neck swelling, perspiration, and fidgeting.

Back 135

C. health-seeking behaviors related to verbalization of wanting to stay healthy.

Front 136

The bony orbit and far cushion of the eye serves as a
A. caruncle.
B. channel.
C. protector.
D. filter.

Back 136

C. protector.

Front 137

The tarsal plates of the upper eyelid contain
A. meibomian glands.
B. sebaceous glands..
C. tear ducts.
D. ocular muscles.

Back 137

A. meibomian glands.

Front 138

The conjunctiva of the eye is divided into the palpebral
portion and the
A. canthus portion.
B. intraocular portion.
C. nasolacrimal portion.
D. bulbar portion.

Back 138

D. bulbar portion.

Front 139

Straight movements of the eye are controlled by the
A. lacrimal muscles.
B. oblique muscles.
C. corneal muscles.
D. rectus muscles.

Back 139

D. rectus muscles.

Front 140

The middle layer of the eye is known as the
A. choroid layer.
B. scleral layer.
C. retinal layer.
D. optic layer.

Back 140

A. choroid layer.

Front 141

Photoreceptors of the eye are located in the eye's
A. ciliary body.
B. lens.
C. retina.
D. pupil.

Back 141

C. retina.

Front 142

The meibomian glands secrete
A. an oily substailce to lubricate the eyes.
B. sweat.
C. hormones.
D. clear liquid tears.

Back 142

A. an oily substailce to lubricate the eyes.

Front 143

The chambers of the eye contain aqueous humor, which helps to
maintain intraocular pressure and
A. transmit light rays.
B. maintain the retinal vessels.
C. change refractory of the lens.
D. cleanse the cornea and the lens.

Back 143

D. cleanse the cornea and the lens.

Front 144

The optic nerves from each eyeball cross at the
A. optic chiasma.
B. vitreous humor.
C. optic disc.
D. visual cortex.

Back 144

A. optic chiasma.

Front 145

The functional reflex that allows the eyes to focus on near
objects is termed
A. pupillary reflex
B. accommodation.
C. refraction.
D. indirect reflex.

Back 145

B. accommodation.

Front 146

While assessing the eyes of an adult client, the nurse uses a wisp of cotton
to stimulate the client's
A. eyelid reflexes.
B. refractory mechanism.
C. lacrimal reflexes.
D. corneal reflexes.

Back 146

D. corneal reflexes.

Front 147

An adult client visits the clinic and tells the nurse that she has had a
sudden change in her vision. 'The nurse should explain to the client that
sudden changes in vision are often associated with
A. diabetes.
B. the aging process.
C. hypertension.
D. head trauma.

Back 147

D. head trauma.

Front 148

An adult client tells the nurse that he has been experiencing gradual vision
loss. The nurse should
A. ask about the client's diet.
B. determine whether there is a history of glaucoma.
C. check the client's blood pressure.
D. ask the client if he has any known allergies.

Back 148

C. check the client's blood pressure.

Front 149

A 45-year-old client tells the nurse that he occasionally sees spots in front
of his eyes. The nurse should
A. tell the client that these often occur with aging.
B. refer the client to an ophthalmologist.
C. re-examine the client in 2 weeks.
D. assess the client for signs of diabetes.

Back 149

A. tell the client that these often occur with aging.

Front 150

An adult client tells the nurse that her peripheral vision isn't what it used
to be and she has a blind spot in her left eye. The nurse should refer the
client for evaluation of possible
A. glaucoma.
B. increased intracranial pressure.
C. bacterial infection.
D. migraine headaches.

Back 150

A. glaucoma.

Front 151

A client visits the local clinic after experiencing head trauma. The client
tells the nurse that he has a consistent blind spot in his right eye. The
nurse should
A. examine the area of head trauma.
B. refer the client to an ophthalmologist.
C. assess the client for double vision.
D. ask the client if he sees "halos."

Back 151

B. refer the client to an ophthalmologist.

Front 152

A client tells the nurse that she has difficulty seeing while driving at night.
The nurse should explain LO the client that night blindness is often
associated with
A. retinal deterioration.
B. head trauma.
C. migraine headaches.
D. vitamin A deficiency.

Back 152

D. vitamin A deficiency.

Front 153

An adult client visits the clinic and tells the nurse that he has been
experiencing double vision for the past few days. The nurse refers the
client to a physician for evaluation of possible
A. glaucoma.
B. increased intracranial pressure.
C. hypertension.
D. ophthalmic migraine.

Back 153

B. increased intracranial pressure.

Front 154

An adult client tells the nurse that she frequently experiences burning and
itching of both eyes. The nurse should assess the client far
A. a foreign body.
B. recent trauma.
C. blind spots.
D. allergies.

Back 154

D. allergies.

Front 155

An adult client visits the outpatient clinic and tells the nurse that he has a
throbbing aching pain in his right eye. The nurse should assess the client
for
A. recent exposure to irritants.
B. increased intracranial pressure.
C. excessive tearing.
D. a foreign body in the eye.

Back 155

D. a foreign body in the eye.

Front 156

An adult client visits the clinic and tells the nurse that he has had
excessive tearing in his left eye. The nurse should assess the client's eye for
A. viral infection.
B. double vision.
C. allergic reactions.
D. lacrimal obstruction.

Back 156

D. lacrimal obstruction.

Front 157

The nurse is caring for a healthy adult client with no history of vision
problems. The nurse should tell the client that a thorough eye exa~nination
is recommended every
A. year.
B. 2 years.
C. 3 years.
D. 4 years.

Back 157

B. 2 years.

Front 158

An adult client tells the nurse that his eyes are painful because he left his
contact lenses in too lon-g the day before yesterday. The nurse should
instruct the client that prolonged wearing of contact lenses can lead to
A. retinal damage.
B. cataracts.
C. myopia.
D. corneal damage.

Back 158

D. corneal damage.

Front 159

An adult client tells the nurse that his father had cataracts. He asks the
nurse about risk factors for cataracts. The nurse should instruct the client
that a potential risk factor is
A. lack of vitamin C in the diet.
B. ultraviolet light exposure.
C. obesity.
D. use of antibiotics.

Back 159

B. ultraviolet light exposure.

Front 160

The nurse is preparing to examine an adult client's eyes, using a Snellen
chart. The nurse should
A. position the client 20 feet away from the chart.
B. ask the client to remove his glasses.
C. ask the client to read each line with both eyes open.
D. instruct the client to begin reading from the bottom of the chart.

Back 160

A. position the client 20 feet away from the chart.

Front 161

A client has tested 20140 on the distant visual acuity test using a Snellen
chart. The nurse should
A. document the results in the client's record.
B. ask the client to read a handheld vision chart.
C. ask the client to return in 2 weeks for another examination.
D. refer the client to an optometrist.

Back 161

D. refer the client to an optometrist.

Front 162

The nurse has tested an adult client's visual fields and determined that the
temporal field is 90 degrees in both eyes. The nurse should
A. refer the client for further evaluation.
B. examine the client for other signs of glaucoma.
C. ask the client if there is a genetic history of blindness.
D. document the findings in the client's records.

Back 162

D. document the findings in the client's records.

Front 163

The nurse has tested the near visual acuity of a 4S-year-old client. The
nurse explains to the client that the client has impaired near vision and
discusses a possible reason for the condition. The nurse determines that
the client has understood the instructions when the client says that
presbyopia is usually due to
A. congenital cataracts.
B. decreased accommodation.
C. muscle weakness.
D. constant misalignment of the eyes.

Back 163

B. decreased accommodation.

Front 164

While assessing the eye of an adult client, the nurse observes an inward
turning of the client's left eye. The nurse should document the client's
A. esotropia.
B. strabismus.
C. phoria.
D. exotropia.

Back 164

A. esotropia.

Front 165

The nurse is examining an adult client's eyes. The nurse has explained the
positions test to the cl~entT. he nurse determines that the client needs
further instructions when the client says that the positions test
A. assesses the muscle strength of the eye.
B. assesses the functioning of the cranial nerves innervating the eye
muscles.
C. requires the coverlng of each eye separately.
D. requires the cl~entto focus on ,In object.

Back 165

C. requires the coverlng of each eye separately.

Front 166

The cone of light is located in the
A. inner ear.
B. middle ear.
C. external ear.
D. semicircular canal.

Back 166

C. external ear.

Front 167

The ossicles contained in the middle ear include the malleus, the incus,
and the
A. pars tensa.
B. pars flaccida.
C. umbo.
D. stapes.

Back 167

D. stapes.

Front 168

Sensory receptors in the ear that help to maintain both static and dynamic
equilibrium are located in the semicircular canals and the
A. vestibule.
B. tympanic membrane.
C. cone of light.
D. eustachian tube.

Back 168

A. vestibule.

Front 169

In the hearing pathway, hair cells of the spiral organ of Corti are stimulated
by movement of
A. fluid.
B. sound.
C. air.
D. bone.

Back 169

A. fluid.

Front 170

The transmission of sound waves through the external ear and middle ear
is known as
A. perceptive hearing.
B. conductive hearing.
C. external hearing.
D. connective hearing.

Back 170

B. conductive hearing.

Front 171

Transmission of sound waves in the inner ear is known as
A. conducive hearing.
B. tympanic hearing.
C. neuromotor hearing.
D. perceptive hearing.

Back 171

D. perceptive hearing.

Front 172

An adult client visits the clinic and complains of tinnitus. The nurse should
ask the client if she has been
A. dizzy.
B. hypotensive.
C. taking antibiotics.
D. experiencing ear drainage.

Back 172

C. taking antibiotics.

Front 173

An adult client tells the nurse that his 80-year-old father is almost
completely deaf. After an explanation to the client about risk factors for
hearing loss, the nurse determines that the client needs further instruction
when the client says
A. "There is a genetic predisposition to hearing loss."
B. "Certain cultural groups have a higher rate of hearing loss."
C. "It is difficult to prevent hearing loss or worsening of hearing."
D. "Chronic otitis media has been associated with hearing loss."

Back 173

C. "It is difficult to prevent hearing loss or worsening of hearing."

Front 174

The nurse is planning to perform an eye and ear examination on an adulr
client. After explaining the procedures to the client, the nurse should
A. ask the client to remain standing.
B. show the client the otoscope.
C. ask the client to remove his contact lenses.
D. observe the client's response to the explanations.

Back 174

D. observe the client's response to the explanations.

Front 175

The nurse i~~preparintog examine the ears of an adult client with an
otoscope. The nurse should plan to
A. ask the client ro tilt the head slightly forward.
B. release the auricle during the examination.
C. use a speculum that measures 10 mm in diameter.
D. firmly pull the auricle out, up, and back.

Back 175

D. firmly pull the auricle out, up, and back.

Front 176

While assessing the ears of an adult client, the nurse observes bloody
drainage in the client's ear. The nurse should
A. docunient the finding in the client's chart.
B. determine whether a foreign body is present in the ear.
C. assess the client for further signs of otitis media.
D. refer the client to a physician.

Back 176

D. refer the client to a physician.

Front 177

While assessing the ears of an adult client, the nurse observes that the
tympanic membrane is completely immobile. The nurse should further
assess the client for signs and symptoms of
A. infection.
B. skull injury.
C. vestibular disorders.
D. healed perforations.

Back 177

A. infection.

Front 178

. The nurse is ~lanningto conduct the Weber test on an adult male client. To
perform this test, the nurse should plan to
A. strike a tuning fork and place it at the base of the client's mastoid
process.
B. whisper a word with two distinct syllables to the client.
C. ask the client to close his eyes while standing with feet together.
D. strike a tunlng fork and place it on the center of the client's head or
forehead.

Back 178

D. strike a tunlng fork and place it on the center of the client's head or
forehead.

Front 179

The nurse has performed the Rinne test on an older adult client. After the
test, the client reports that her bone conduction sound was heard longer
than the air corlduction sound. The nurse determines that the client is most
likely experiencing
A. normal hearing.
B. sensorineural hearing loss.
C. conductive hearing loss.
D. central hearing loss.

Back 179

C. conductive hearing loss.

Front 180

The roof of the oral cavity of the mouth is formed by the anterior hard palate and the
A. teeth.
B. gums.
C. muscles.
D. soft palate.

Back 180

D. soft palate.

Front 181

An extension of the soft palate of the mouth, which hangs in the posterior
midline of the oropbarynx, is the
A. uvula.
B. frenulum.
C. taste buds.
D. sublingual fold.

Back 181

A. uvula.

Front 182

The tongue is attached to the hyoid bone and styloid process of the
temporal bone and is connected to the floor of the mouth by the
A. mandible.
B. frenulum.
C. gums.
D. soft palate.

Back 182

B. frenulum.

Front 183

The submandibular glands open under the tongue through openings called
A. parasinal ducts.
B. Stensen's ducts.
C. Wharton's ducts.
D. lacrimonasal ducts.

Back 183

C. Wharton's ducts.

Front 184

The rich blood supply of the nose serves to
A. help propel moist air to the body.
8. pcopel debris to the throat.
C. filter large particles from the air.
D. warm the inspired air.

Back 184

D. warm the inspired air.

Front 185

The nurse is preparing to examine the sinuses of an adult client. After
examining the frontal sinuses, the nurse should proceed to examine the
A. ethmoidal sinuses.
B. laryngeal sinuses.
C. maxillary sinuses.
D. sphenoidal sinuses.

Back 185

C. maxillary sinuses.

Front 186

An adult client visits the clirlic complaining of recurrent ulcers in the
mouth. The nurse assesses the client's mouth and observes a painful
ulcer. The nurse should document the presence of
A. a cancerous lesion.
B. Candida albicarzs infection
C. an oral ulceration.
D. aplithous stomatitis.

Back 186

D. aplithous stomatitis.

Front 187

A nurse assesses the mouth of an adlilt male cl~enat nd observes a rough,
crusty, eroded area. The nurse should
A. refer the client for further evaluation.
B. document the presence of herpes simplex.
C. ask the client if his gums bleed.
D. documelit the presence of a canker sore.

Back 187

A. refer the client for further evaluation.

Front 188

An adult client visits the clinic and tells the nurse that she has been
experiencing frequent nosebleeds for the past month. The nurse should
A. ask the client if she has had recent oral surgery.
B. assess the client's nasal passages for blockage.
C. ask the client if she is a smoker.
D. refer the client for further evaluation.

Back 188

D. refer the client for further evaluation.

Front 189

The nurse is assessing the mouth of an older adult and observes that the
client appears to have poorly fitting dentures. The nurse should instruct
the client that she may be at greater risk for
A. aspiration.
B. malocclusion.
C. gingivitis.
D. throat soreness.

Back 189

A. aspiration.

Front 190

An adolescent client tells the nurse that her mother says she ginds her
teeth when she sleeps. The nurse should explain to the client that
grinding the teeth may be a sign of
A. precancerous lesions.
B. poor oral hygiene.
C. malabsorption.
D. stress and anxiety.

Back 190

D. stress and anxiety.

Front 191

The nurse is planning a presentation to a group of high school
students about the risk factors for oral cancer. Which of the following
should be included in the nurse's plan?
A. Diets low in fruits and vegetables are a possible risk factor for oral cancer.
B. About 40% of all cancers occur in the lips, mouth, and tongue.
C. The incidence of oral cancers is higher in women than in men.
D. Most oral cancers are detected in people in their 70s.

Back 191

A. Diets low in fruits and vegetables are a possible risk factor for oral cancer.

Front 192

Before examining the mouth of an adult client, the nurse sliould first
A. ask the client to leave dentures in place.
B. don sterile gloves for the procedure.
C. offer the client mouthwash.
D. don clean gloves for the procedure.

Back 192

D. don clean gloves for the procedure.

Front 193

A client visits the clinic and tells the nurse that she has painful cracking in
the corners of her lips. The nurse should assess the client's diet for 3
deficiency of
A. vitamin C.
B. fluoride.
C. vitamin A.
D. riboflavin.

Back 193

D. riboflavin.

Front 194

The nurse is assessing a client who has been taking antibiotics for an
infection for 10 days. The nurse observes whitish curd-like patches in the
client's mouth. The nurse should explain to the client that these spots are
most likely
A. Candida albicans infection.
B. Koplik's spots.
C. leukoplakia.
D. Fordyce spots.

Back 194

A. Candida albicans infection.

Front 195

The nurse is assessing an adult client's oral cavity for possible oral
cancer. The nurse should explain to the client that the most common
site of oral cancer is the
A. area on top of the tongue.
B. area underneath the tongue.
C. inside of the cheeks.
D. area near the salivary glands.

Back 195

B. area underneath the tongue.

Front 196

The nurse is planning to inspect an adult client's mouth, using a
tongue depressor. The nurse should plan to
A. depress the tongue blade slightly off center.
B. depress the tongue blade as close to the center as possible.
C. ask the client to keep the mouth partially open.
D. insert the tongue blade at the back of the client's tongue.

Back 196

A. depress the tongue blade slightly off center.

Front 197

An adult client visits the clinic complaining of a sore throat. After
assessing the throat, the nurse documents the client's tonsils as 4+. The
nurse should explain to llle client that 4+ tonsils are present when the
nurse observes tonsils that are
A. touching the uvula.
B. visible upon inspection.
C. touching each other.
D. midway between the tonsillar pillars and uvula.

Back 197

C. touching each other.

Front 198

The nurse is preparing to inspect the nose of an adult client with an
otoscope. The nurse plans to
A. position the handle of the otoscope to one side.
B. tip the client's head as far back as possible.
C. direct the otoscope tip quickly back and down the nostril.
D. position the handle of the otoscope straight and up.

Back 198

A. position the handle of the otoscope to one side.

Front 199

The nurse has assessed the nose of an adult client and has explained to the
client about her thick yellowish nasal discharge. The nurse determines
that the client understands the instructions when the client says that the
yellowish discharge is 113ost likely due to
A. too much smoking.
B. chronic allergies.
C. trauma to the nasal passages.
D. an upper respiratory infection.

Back 199

D. an upper respiratory infection.

Front 200

The clavicles extend fron~th e acrornion of the scapula to the part of the sternum termed the
A. body.
B. xiphoid process.
C. angle.
D. manubriurn.

Back 200

D. manubriurn.

Front 201

A bony ridge located at the point where the ~nanubriurna rticulates with the
body of the sternum is termed the sternal
A. angle.
B. notch.
C. space.
D. prominens.

Back 201

A. angle.

Front 202

The spinous process termed the vertebra prominens is which cervical
vertebra?
A. Fifth
B. Sixth
C. Seventh
D. Eighth

Back 202

C. Seventh

Front 203

The apex of each lung is located at the
A. level of the diaphragm.
B. area slightly above the clavicle.
C. level of the sixth rib.
D. left oblique fissure.

Back 203

B. area slightly above the clavicle.

Front 204

l'he tlli~id o~ll~le-layresedr ous membrane that lines the chest cavity is
termed
A. parietal pleura.
B. pulmonary pleura.
C. visceral pleura.
D. thoracic pleura.

Back 204

A. parietal pleura

Front 205

The lining of tlie trachea and bronchi, which serves to remove dust, foreign
bodies, and bacteria, is termed the
A. bronchioles.
B. alveolar sacs.
C. alveolar ducts.
D. cilia.

Back 205

D. cilia.

Front 206

Under normal circumstances, the strongest stimulus in a human being to
breathe is
A. hypoxemia.
B. hypocapnia.
C. pH changes.
D. hypercapnia.

Back 206

D. hypercapnia.

Front 207

While assessing an adult client, the client tells the nurse that she "has had
difficulty catching her breath since yesterday." The nurse should assess the
client further for signs and symptoms of
A. emphysema.
B. cardiac disease.
C. trauma to the chest.
D. infection.

Back 207

D. infection.

Front 208

An adult client visits the clinic and tells the nurse that he has been
"spitting up rust-colored sputum." The nurse should refer the client to the
physician for possible
A. pulmonary edema.
B. bronchitis.
C. asthma.
D. tuberculosis.

Back 208

D. tuberculosis.

Front 209

The nurse is planning a presentation to a group of high school students on
the topic of lung cancer. Which of the followillg should the nurse plan to
include in the presentation?
A. Compared with whites in the United States, African Americans have a
lower incidence of lung cancer.
B. Lung cancer is the third leading cause of death in the United States.
C. There is a higher incidence of lui~gc ancer in women than men in the
United States.
D. Studies have indicated a genetic component in the development of lung
cancer.

Back 209

D. Studies have indicated a genetic component in the development of lung
cancer.

Front 210

While assessing an adult client, the nurse observes decreased chest
expansion at the bases of the client's lu~lgsT. he nurse should refer the
client to a physician for possible
A. atelectasis.
B. pneumonia.
C. chest trauma.
D. chronic obstructive pullnonary disease.

Back 210

D. chronic obstructive pullnonary disease.

Front 211

The nurse is planning to percuss the chest of an adult male client for
diaphragmatic excursion. The nurse should begin the assessment by
A. asking the client to take a deep breath and hold it.
B. percussing upward from the base of the lungs.
C. percussing downward until the tone changes to resonance.
D. asking the client to exhale forcefully and hold his breath.

Back 211

D. asking the client to exhale forcefully and hold his breath.

Front 212

The nurse is preparing to auscultate the posterior thorax of an adult
female client. The nurse should
A. place the bell of the stethoscope firmly on the posterior chest wall.
B. auscultate from the base of the lungs to the apices.
C. ask the client to breathe deeply through her mouth.
D. ask the client to breathe normally through her nose.

Back 212

C. ask the client to breathe deeply through her mouth.

Front 213

While assessing the thoracic area of an adult client, the nurse plans to
auscultate for voice sounds. To assess bronchophony, the nurse should ask
the client to
A. repeat the phrase "ninety-nine."
B. repeat the letter "E."
C. whisper the phrase "one-two-three."
D. repeat the letter "A."

Back 213

A. repeat the phrase "ninety-nine."

Front 214

The nurse assesses an adult client's thoracic area and observes a markedly
sunken sternum and adjacent cartilages. The nurse should document the
client's
A. pectus thorax.
B. pectus excavatum.
C. pectus carinatum.
D. pectus diaphragm.

Back 214

B. pectus excavatum

Front 215

The nurse assesses an adult client and observes that the client's breathing
pattern is very labored and noisy, with occasional coughing. The nurse
should refer the client to a physician for possible
A. chronic bronchitis.
B. atelectasis.
C. renal failure.
D. congestive heart failure.

Back 215

A. chronic bronchitis.

Front 216

While assessing an adult client's lungs during the postoperative period, the
nurse detects coarse crackles. The nurse should refer the client to a physician
for possible
A. pneumonia.
B. pleuritis.
C. bronchitis.
D. asthma.

Back 216

A. pneumonia.

Front 217

The nurse assesses an adult client's breath sounds and hears sonorous
wheezes, primarily during the client's expiration. The nurse should refer
the client to a physician for possible
A. asthma.
B. chronic emphysema.
C. pleuritis.
D. bronchitis.

Back 217

D. bronchitis.

Front 218

The nurse has assessed the respiratory pattern of an adult client. The
nurse determines that the client is exhibiting Kussmaul's respirations with
hyperventilation. The nurse should contact the client's physician because
this type of respiratory pattern usually indicates
A. diabetic ketoacidosis.
B. central nervous system injury.
C. drug overdose.
D. congestive heart failure.

Back 218

A. diabetic ketoacidosis.

Front 219

At puberty, the female breasts enlarge in response to estrogen and
A. progesterone.
B. aldosterone.
C. lactogen.
D. prolactin.

Back 219

A. progesterone.

Front 220

Elevated sebaceous glands, known as Montgomery's glands, are located in
the breast's
A. nipples.
B. hair follicles.
C. lactiferous ducts.
D. areolas.

Back 220

D. areolas.

Front 221

The functional part of the breast that allows for milk production consists
of tissue termed
A. fibrous.
B. glandular.
C. adipose.
D. lactiferous.

Back 221

B. glandular.

Front 222

Fibrous tissue that provides support for the glandular tissue of the breasts
is termed
A. lateral ligaments.
B. Wharton's ligaments.
C. pectoral ligaments.
D. Cooper's ligaments.

Back 222

D. Cooper's ligaments.

Front 223

The size and shape of the breasts in females is related to the amount of
A. glandular tissue.
B. fibrous tissue.
C. lactiferous ducts.
D. fatty tissue.

Back 223

D. fatty tissue.

Front 224

The lymph nodes that are responsible for drainage from the arms are the
A. lateral lymph nodes.
B. central lymph nodes.
C. anterior lymph nodes.
D. posterior lymph nodes.

Back 224

A. lateral lymph nodes

Front 225

After assessing the breasts of a female client, the nurse should explain to
the client that most breast tumors occur in the
A. upper inner quadrant.
B. lower inner quadrant.
C. upper outer quadrant.
D. lower outer quadrant.

Back 225

C. upper outer quadrant.

Front 226

A temale client tells the nurse that her breasts become lumpy and sore before
menstruation but get better at the end of the n~enstrualc ycle. The nurse
should explain to the client that these symptoms are often associated with
A. malignant tumors.
B. fibroadenoma.
C. fibrocystic breast disease.
D. increased estrogen production.

Back 226

C. fibrocystic breast disease.

Front 227

The nurse has discussed the risks for breast cancer with a group of high
school seniors. The nurse determines that one of the students needs further
instructions when the student says that one risk factor is
A. having a baby before the age of 20 years.
B. a family history of breast cancer.
C. consumption of a high-fat diet.
D. late menopause.

Back 227

A. having a baby before the age of 20 years.

Front 228

Cultural beliefs about the causes of breast cancer do not always agree with
medical findings. Hispanic Americans often associate breast cancer with
A. improper diet.
B. punishment from God.
C. physical stress.
D. evil thoughts.

Back 228

C. physical stress.

Front 229

The nurse is working with a community group to set up teaching
programs to increase awareness among African-American women about
preventive screening techniques for breast cancer. In the teaching
program, the nurse should plan to include
A. local female physicians who work with cancer clients.
B. hospital clinic workers from various racial backgrounds.
C. nurses who work in outpatient centers.
D. breast cancer patients of the same race.

Back 229

D. breast cancer patients of the same race.

Front 230

The nurse is caring- for an adult female client when the client tells the
nurse that she has had a clear discharge from her nipples for the past
month. The nurse should ask the client if she has been taking
A. antidepressants.
B. antibiotics.
C. insulin.
D. contraceptives.

Back 230

D. contraceptives.

Front 231

The nurse is assessing an adult male client when the nurse observes
gynecomastia in the client. The nurse should ask the client if he is taking
any medications for
A. inflammation.
B. depression.
C. infection.
D. ulcers.

Back 231

B. depression.

Front 232

The nurse is caring for a female client who has received a diagnosis of
fibrocystic breast disease. The nurse has instructed the client about the
disease. The nurse determines that the client needs further instructions
when the client says she should avoid drinking
A. regular coffee.
B. regular tea.
C. diet colas.
D. grapefruit juice.

Back 232

D. grapefruit juice.

Front 233

The nurse plans to instruct an adult female client with regular menstrual
cycles, who is not taking oral contraceptives, about breast selfexamination.
The nurse should plan to instruct the client to perform
breast self-examination
A. during menstruation.
B. on the same day every month.
C. midway between the cycles.
D. right after menstruation.

Back 233

D. right after menstruation

Front 234

The nurse observes an orange-peel appearance, or peau d'orange, of the
areolae of a client's breasts. The nurse should explain to the client that
this is most likely due to
A. blocked lymphatic drainage.
B. fibrocystic breast disease.
C. fibroadenomas.
D. radiation therapy.

Back 234

A. blocked lymphatic drainage.

Front 235

The nurse is assessing a SO-year-old client's breasts and observes a
spontaneous discharge of fluid from the left nipple. The nurse should
A. document this as a normal finding.
B. ask the client if she has had retracted nipples.
C. refer the client for a cytology examination.
D. determine whether the client wears a supportive bra.

Back 235

C. refer the client for a cytology examination

Front 236

The nurse observes dimpling in an adult female client's breasts. The nurse
should explain to the client that dimpling of the breast may indicate a
A. fibroadenoma
B. tumor.
C. genetic deviation.
D. fibrocystic breast.

Back 236

B. tumor.

Front 237

The nurse is preparing to examine the breasts of a female client who had
a left radical mastectomy 3 years ago. When examining the client, the
nurse observes redness at the scar area. The nurse should explain to the
client that this may be indicative of
A. additional tumors.
B. poor lymphatic drainage.
C. an infectious process.
D. metastasis to the right breast.

Back 237

C. an infectious process.

Front 238

A client has had a recent mastectomy and visits the clinic for
postoperative evaluation. The client tells the nurse that she has been
depressed and feels as if she is no longer a woman. The most appropriate
nursing diagnosis for this client is
A. Ineffective individual coping related to mastectomy.
B. Fear of additional breast cancer related to presence of risk factors.
C. PC: Hematoma after mastectomy.
D. Disturbed body image related to mastectomy.

Back 238

D. Disturbed body image related to mastectomy.

Front 239

The anterior chest area that overlies the heart and great vessels is called the
A. precordium.
B. epicardium.
C. myocardium.
D. endocardium.

Back 239

A. precordium.

Front 240

The bicuspid, or mitral, valve is located
A. between the left atrium and the left ventricle.
B. between the right atrium and the right ventricle.
C. at the beginning of the ascending aorta.
D. at the exit of each ventricle near the great vessels.

Back 240

A. between the left atrium and the left ventricle.

Front 241

The semilunar valves are located
A. at the exit of each ventricle at the beginning of the great vessels.
B. between the right atrium and the right ventricle.
C. between the left atrium and the left ventricle.
D. at the beginning of the ascending aorta.

Back 241

A. at the exit of each ventricle at the beginning of the great vessels.

Front 242

The sinoatrial node of the heart is located on the
A. posterior wall of the right atrium.
B. anterior wall of the right atrium.
C. upper intraventricular system.
D. anterior wall of the left atrium.

Back 242

A. posterior wall of the right atrium.

Front 243

The P-wave phase of an electrocardiogram (ECG) represents
A. conduction of the impulse throughout the atria.
B. conduction of the impulse throughout the ventricles.
C. ventricular repolarization.
D. ventricular polarization.

Back 243

A. conduction of the impulse throughout the atria.

Front 244

During a cardiac examination, the nurse can best hear the S, heart sound
by placing the stethoscope at the client's
A. base of the heart.
B. pulmonic valve area.
C. apex of the heart.
D. second left interspace.

Back 244

C. apex of the heart.

Front 245

The 5, heart sound
A. can be heard during systole.
B. is often termed ventricular gallop.
C. is usually due to a heart murmur.
D. can be heard during diastole.

Back 245

D. can be heard during diastole.

Front 246

An adrllt client visits the clinic and tells the nurse that she feels chest pain
and pain down her left arm. The nurse should refer the client to a
physician for possible
A. congestive heart failure.
B. anglna.
C. palpitations.
D. acute anxiety reaction.

Back 246

B. anglna.

Front 247

A11 adult client tells the nurse that his father died of a massive coronary at
the age of 65. The nurse should explain to the client that one of the risk
factors for coronary heart disease is
A. high serum level of low-density lipoproteins.
B. low carbohydrate diets.
C. high serum level of high-density lipoproteins.
D. diets that are hig- h in antioxidant vitamins.

Back 247

A. high serum level of low-density lipoproteins.

Front 248

The nurse is planning a presentation about coronary heart disease for a
group of middle-aged adults. Which of the following should be included
in the nurse's teaching plan?
A. Hispanic clients have a higher incidence of CHD than black or white
Americans.
B. The incidence of hypertension in the white popi~lationo f the IJnited
States is greater than in the black population.
C. Women are more likely to have serious stenosis after a heart attack.
D. Estrogen replacement therapy in postmenopausal women decreases the
risk of heart attack.

Back 248

D. Estrogen replacement therapy in postmenopausal women decreases the
risk of heart attack.

Front 249

The nurse is preparing to assess the cardiovascular system of an adult
client with emphysema. The nurse anticipates that there [nay be some
difficulty palpating the client's
A. apical pulse.
B. breath sounds.
C. jugular veins.
D. carotid arteries.

Back 249

A. apical pulse.

Front 250

The nurse is planning to auscultate a female adult client's carotid arteries.
The nurse should plan to
A. ask the client to hold her breath.
B. palpate the arteries before auscultation.
C. place the diaphragm of the stethoscope over the artery.
D. ask the client to breathe normally.

Back 250

A. ask the client to hold her breath.

Front 251

While assessing an older adult client, the nurse detects a bruit over the
carotid artery. The nurse should explain to the client that a bruit is
A. a normal sound heard in adult clients.
B. a wheezing sound.
C. associated with occlusive arterial disease.
D. heard when the artery is almost totally occluded.

Back 251

C. associated with occlusive arterial disease.

Front 252

The nurse assesses a hospitalized adult client and observes that the client's
jugular veins are fully extended. The nurse contacts the client's physician
because the client's signs are indicative of
A. pulmonary emphysema.
B. diastolic murmurs.
C. patent ductus arteriosus.
D. increased central venous pressure.

Back 252

D. increased central venous pressure.

Front 253

While palpating the apex, left sternal border, and base in an adult client,
the nurse detects a thrill. The nurse should further assess the client for
A. cardiac murmur.
B. left-sided heart failure.
C. constrictive pericarditis.
D. congestive heart failure.

Back 253

A. cardiac murmur.

Front 254

The nurse is auscultating the heart sounds of an adult client. To auscultate
Erb's point, the nurse should place the stethoscope at the
A. second intercostal space at the right sternal border.
B. third to fifth intercostal space at thc left stcrnal border.
C. apex of the heart near the midclavicular line.
D. fourth or fifth intercostal space at the left lower sternal border.

Back 254

B. third to fifth intercostal space at thc left stcrnal border.

Front 255

While auscultating an adult client's heart rate and rhythm, the nurse detects
a regular irregular pattern. The nurse should
A. assess the client for signs and symptoms of pulmonary disease.
B. document this as a normal finding.
C. schedule the client for an EGG.
D. refer the client to a physician.

Back 255

D. refer the client to a physician.

Front 256

The nurse has assessed the heart sounds of an adolescent client and detects
the presence of an Sj heart sound at the beginning of the diastolic pause. The
nurse sllo~~ilnds truct the client that she should
A. be referred to a cardiologist for further evaluation.
B. be examined again in 6 months.
C. restrict exercise and strenuous activities.
D. recognize that this finding is normal in adolescents.

Back 256

D. recognize that this finding is normal in adolescents.

Front 257

While assessing an adult client, the nurse detects opening snaps early in
diastole during auscultation of the heart. The nurse should refer the client
to a physician because this is usually indicative of
A. pulmonary hypertension.
B. aortic stenosis.
C. mitral valve stenosis.
D. puln~onary hypotension.

Back 257

C. mitral valve stenosis.

Front 258

The nurse detects paradoxical pulses in an adult client during an
examination. The nurse should explain to the client that paradoxical
pulses are usually indicative of
A. obstructive lung disease.
B. left-sided heart failure.
C. premature ventricular contractions.
D. aortic stenosis.

Back 258

A. obstructive lung disease

Front 259

The nurse is assessing an adult client with a diagnosis of sinus arrhythmia.
The nurse should explain to the client that this indicates that the
A. heartbeats are followed by a pause.
B. ventricular contraction occurs irregularly.
C. S, and S2 sounds are both split.
D. heart rate speeds up and slows down during a cycle.

Back 259

D. heart rate speeds up and slows down during a cycle.

Front 260

The fourth heart sound, S,"", is aian
A. low-frequency sound best heard with the bell of the stethoscope.
B. abnormal finding in trained athletes.
C. sound that can be heard in the absence of atrial contraction.
D. sound that may increase during expiration.

Back 260

A. low-frequency sound best heard with the bell of the stethoscope.

Front 261

The major artery that supplies blood to the arm is the
A. radial artery.
B. ulnar artery.
C. posterior artery.
D. brachial artery.

Back 261

D. brachial artery.

Front 262

The popliteal artery can be palpated at the
A. knee.
B. great toe.
C. ankle.
D. inguinal ligament.

Back 262

A. knee.

Front 263

The posterior tibia1 pulse can be palpated at the
A. great toe.
B. knee.
C. top of the foot.
D. ankle.

Back 263

D. ankle.

Front 264

Blood from the lower trunk and legs drains upward into the inferior vena
cava. The percentage of the body's blood volume that is contained in the
veins is nearly
A. 50%.
B. 60%.
C. 70%.
D. 80%.

Back 264

C. 70%.

Front 265

While assessing the peripheral vascular system of an adult client, the nurse
detects cold clammy skin and loss of hair on the client's legs. The nurse
suspects that the client may be experiencing
A. venous stasis.
B. varicose veins.
C. thrombophlebitis.
D. arterial insufficiency.

Back 265

D. arterial insufficiency.

Front 266

During a physical examination, the nurse detects warm skin and brown
pigmentation around an adult client's ankles. The nurse suspects that the
client may be experiencing
A. venous insufficiency.
B. arterial occlusive disease.
C. venous ulcers.
D. ankle edema.

Back 266

A. venous insufficiency.

Front 267

The nurse is assessing the peripheral vascular systm of an older adult
client. The client tells the nurse that her legs "seem cold all the time and
sometimes feel tingly." The nurse suspects that the client may be
experiencing
A. varicose veins.
B. intermittent claudication.
C. edema.
D. thrombophlebitis.

Back 267

B. intermittent claudication.

Front 268

The nurse is caring for a client who is employed as a typist and has a
family history of peripheral vascular disease. The nurse should instruct
the client to reduce her risk factors by
A. eating a high-protein diet.
B. resting frequently.
C. drinking large quantities of milk.
D. getting regular exercise.

Back 268

D. getting regular exercise.

Front 269

The nurse is preparing to use a Doppler ultrasound probe to detect blood flow in the femoral artery of an adult client. The nurse should
A. apply K-Y jelly to the client's skin.
B. place the client in a supine position with the head flat.
C. place the tip of the probe in a 30-degree angle to the artery.
D. apply gel used for electrocardiography (ECG) to the client's skin.

Back 269

A. apply K-Y jelly to the client's skin.

Front 270

A client visits the clinic and tells the nurse that she had a mastectomy
2 years ago. The nurse should assess the client for
A. lymphedema.
B. Raynaud's disease.
C. poor peripheral pulses.
D. bruits over the radial artery.

Back 270

A. lymphedema.

Front 271

After palpating the radial pulse of an adult client, the nurse suspects
arterial insufficiency. The nurse should next assess the client's
A. femoral pulse.
B. popliteal pulse.
C. brachial pulse.
D. tibial pulse.

Back 271

C. brachial pulse.

Front 272

The nurse is preparing to palpate the epitrochlear lymph nodes of an
adult male client. The nurse should instruct the client to
A. assume a supine position.
B. rest his arm on the examination table.
C. flex his elbow about 90 degrees.
D. make a fist with his left hand.

Back 272

C. flex his elbow about 90 degrees.

Front 273

While inspecting the skin color of a male client's legs, the nurse observes
that the client's legs are slightly cyanotic while he is sitting on the edge of
the examination table. The nurse should refer the client to a physician for
possible
A. arterial insufficiency.
B. congestive heart failure.
C. Raynaud's disease.
D. venous insufficiency.

Back 273

D. venous insufficiency.

Front 274

While assessing the inguinal lymph nodes in an older adult client, the
nurse detects that the lymph nodes are approximately 3 centimeters in
diameter, nontender, and fixed. The nurse should refer the client to a
physician because these findings are generally associated with
A. localized infection.
B. systemic infection.
C. arterial insufficiency.
D. malignancy.

Back 274

D. malignancy.

Front 275

The nurse plans to assess an adult client for Homans' sign. The nurse
should
A. ask the client to remain standing for the procedure.
B. place the hands on the client's thigh muscle.
C. place the hands near the client's ankle.
D. flex the client's knee, then dorsiflex the foot.

Back 275

D. flex the client's knee, then dorsiflex the foot.

Front 276

The nurse is planning to perform the Trendelenburg test 011 an adult
client. The nurse should explain to the client that this test is used to
determine the
A. degree of arterial occlusion that exists.
B. pulse of a client with poor elasticity.
C. competence of the saphenous vein valves.
D. severity of thrombophlebitis.

Back 276

C. competence of the saphenous vein valves.

Front 277

The abdominal contents are enclosed externally by the abdominal wall
musculature-three layers of muscle extending from the back, around the
flanks, to the front. The outer muscle layer is the external
A. rectal abdominis.
B. transverse abdominis.
C. abdominal oblique.
D. umbilical oblique.

Back 277

C. abdominal oblique.

Front 278

The sigmoid colon is located in this area of the abdomen: the
A. left upper quadrant.
B. left lower quadrant.
C. right upper quadrant.
D. right lower quadrant.

Back 278

B. left lower quadrant.

Front 279

The pancreas of an adult client is located
A. below the diaphragm and extending below the right costal margin.
B. posterior to the left midaxillary line and posterior to the stomach.
C. high and deep under the diaphragm and can be palpated.
D. deep in the upper abdomen and is not normally palpable.

Back 279

D. deep in the upper abdomen and is not normally palpable.

Front 280

The primary function of the gallbladder is to
A. store and excrete bile.
B. aid in the digestion of protein.
C. produce alkaline mucus.
D. produce hormones.

Back 280

A. store and excrete bile.

Front 281

The colon originates in this abdominal urea: the
A. right lower quadrant.
B. right upper quadrant.
C. left lower quadrant.
D. left upper quadrant.

Back 281

A. right lower quadrant.

Front 282

To percuss the liver of an adult client, the nurse should begin the
abdominal assessment at the client's
A. right upper quadrant.
B. right lower quadrant.
C. left upper quadrant.
D. left lower quadrant.

Back 282

A. right upper quadrant.

Front 283

To palpate for tenderness of an adult client's appendix, the nurse should
beg& the abdominal assessment at the client's
A. left upper quadrant
B. left lower quadrant.
C. right upper quadrant.
D. right lower quadrant.

Back 283

D. right lower quadrant.

Front 284

To palpate the spleen of an adult client, the nurse should begin the
abdominal assessment of the client at the
A. left lower quadrant
B. left upper quadrant.
C. right upper quadrant.
D. right lower quadrant.

Back 284

B. left upper quadrant.

Front 285

The nurse plans to assess an adult client's kidneys for tenderness.
The nurse should assess the area at the
A. right upper quadrant
B. left upper quadrant.
C. external oblique angle.
D. costovertebral angle.

Back 285

D. costovertebral angle.

Front 286

A client visits the clinic because she experienced bright hematemesis
yesterday. The nurse should refer the client to a physician because this
symptom is indicative of
A. stomach ulcers.
B. pancreatic cancer.
C. decreased gastric motility.
D. abdominal tumors.

Back 286

A. stomach ulcers.

Front 287

The nurse is assessing an older adult client who has lost 5 pounds since
her last visit 1 year ago. The client tells the nurse that her husband died
2 months ago. The nurse should further assess the client for
A. peptic ulcer.
B. bulimia.
C. appetite changes.
D. pancreatic disorders.

Back 287

C. appetite changes.

Front 288

A client visits the clinic for a routine examination. The client tells the
nurse 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 can decrease the constipation if I eat foods high in fiber and drink
water."
B. "I should cut down on the number of iron tablets I am taking each day."
C. "Constipation should decrease if I take the iron tablets with milk."
D. "I should discontinue the iron tablets and eat foods that are high in
iron."

Back 288

A. "I can decrease the constipation if I eat foods high in fiber and drink
water."

Front 289

The nurse is caring for a female client during her first postoperative day
after a temporary colostomy. The client refuses to look at the colostomy
bag or the area. A priority nursing diagnosis for this client is
A. Denial related to temporary colostomy.
B. Fear related to potential outcome of surgery.
C. Disturbed body image related to temporary colostomy.
D. Altered role functioning related to frequent colostomy bag changes.

Back 289

C. Disturbed body image related to temporary colostomy.

Front 290

The nurse is preparing to assess the abdomen of a hospitalized client 2 days
after abdominal surgery. The nurse should first
A. palpate the incision site.
B. auscultate for bowel sounds.
C. percuss for tympany.
D. inspect the abdominal area.

Back 290

D. inspect the abdominal area.

Front 291

The nurse is planning to assess the abdomen of an adult male client.
Before the nurse begins the assessment, the nurse should
A. ask the client to empty his bladder.
B. place the client in a side-lying position.
C. ask the client to hold his breath for a few seconds.
D. tell the client to raise his arms above his head.

Back 291

A. ask the client to empty his bladder.

Front 292

The nurse is assessing the abdomen of an adult client and observes a
purple discoloration at the flanks. The nurse should refer the client to a
physician for possible
A. liver disease.
B. abdominal distention.
C. Cushing's syndrome.
D. internal bleeding.

Back 292

D. internal bleeding.

Front 293

While assessing an adult client's abdomen, the nurse observes that the
client's umbilicus is deviated to the left. The nurse should refer the client
to a physician for possible
A. gallbladder disease.
B. cachexia.
C. kidney trauma.
D. masses.

Back 293

D. masses.

Front 294

While assessing an adult client's abdomen, the nurse observes that the
client's umbilicus is enlarged and everted. The nurse should refer the client
to a physician for possible
A. umbilical hernia.
B. ascites.
C. intra-abdominal bleeding.
D. pancrearitis.

Back 294

A. umbilical hernia.

Front 295

The nurse assesses an adult male client's abdomen and observes
diminished abdominal respiration. The nurse determines that the client
should be further assessed for
A. liver disease.
B. umbilical hernia.
C. intestinal obstruction.
D. peritoneal irritation.

Back 295

D. peritoneal irritation.

Front 296

The nurse is assessing the bowel sounds of an adult client. After listening to
each quadrant, the nurse determines that bowel sounds are not present. The
nurse should refer the client to a physician for possible
A. aortic aneurysm.
B. paralytic ileus.
C. gastroenteritis.
D. fluid and electrolyte imbalances.

Back 296

B. paralytic ileus.

Front 297

While assessing the abdominal sounds of an adult client, the nurse hears
high-pitched tingling sounds throughout the distended abdomen. The
nurse should refer the client to a physician for possible
A. intestinal obstruction.
B. gastroenteritis.
C. inflamed appendix.
D. cirrhosis of the liver.

Back 297

A. intestinal obstruction.

Front 298

During a physical examination of an adult client, the nurse is preparing to
auscultate the client's abdomen. The nurse should
A. palpate the abdomen before auscultation.
B. listen in each quadrant for 15 seconds.
C. use the diaphragm of the stethoscope.
D. begin auscultation in the left upper quadrant.

Back 298

C. use the diaphragm of the stethoscope.

Front 299

To palpate the spleen of an adult client, the nurse should
A. ask the client to exhale deeply.
B. place the right hand below the left costal margin.
C. point the fingers of the left hand downward.
D. ask the client to remain in a supine position.

Back 299

B. place the right hand below the left costal margin.

Front 300

The nurse is planning to assess a client's abdomen for rebound tenderness.
The nurse should
A. perform this abdominal assessment first.
B. ask the client to assume a side-lying position.
C. palpate lightly while slowly releasing pressure.
D. palpate deeply while quickly releasing pressure.

Back 300

D. palpate deeply while quickly releasing pressure.

Front 301

To assess an adult client for possible appendicitis and a positive psoas
sign, the nurse should
A. rotate the client's knee internally.
B. palpate at the lower right quadrant.
C. raise the client's right leg from the hip.
D. support the client's right knee and ankle.

Back 301

C. raise the client's right leg from the hip.

Front 302

The skin folds of the labia rnajora are composed of adipose tissue,
sebaceous glands, and
A. Skene's ducts.
B. vestibular glands.
C. sweat glands.
D. Bartholin's glands.

Back 302

C. sweat glands.

Front 303

The visible portion of the clitoris is termed the
A. corpus.
B. crura.
C. vestibule.
D. glans.

Back 303

D. glans.

Front 304

The skin folds of the labia majora and the labia minora form a boat-shaped
area termed the
A. vestibule.
B. corpus.
C. Skcnc's glands.
A D. urethral meatus.

Back 304

A. vestibule.

Front 305

The outermost layer of the vaginal wall is composed of
A. pink squamous epithelium and connective tissue.
B. the vascular supply, nerves, and lymphatic channels.
C. smooth muscle and connective tissue.
D. connective tissue and the vascular network.

Back 305

A. pink squamous epithelium and connective tissue.

Front 306

The outer layer of the vaginal wall is under the direct influence of
A. androgen.
B. progesterone.
C. aldosterone.
D. estrogen.

Back 306

D. estrogen.

Front 307

A female client tells the nurse that she may be experiencing premenstrual
syndrome. An appropriate question for the nurse to ask the client is
A. "How often are your menstrual periods?"
B. "Do you experience mood swings or bloating?"
C. "Are you experiencing regular menstrual cycles?"
D. "How old were you when you began to menstruate?"

Back 307

B. "Do you experience mood swings or bloating?"

Front 308

menopausal phase of her life. The nurse should instruct the client that she
may experience
A. hot flashes.
B. increased appetite.
C. vaginal discharge.
D. urinary frequency.

Back 308

A. hot flashes.

Front 309

During assessment of the vaginal area of an adult client, the client tells the
nurse that she has had pain in her vaginal area. The nurse should further
assess the client for
A. trauma.
B. cancer.
C. pregnancy.
D. infection.

Back 309

D. infection.

Front 310

A female client tells the nurse that she has pain while urinating. Besides
obtaining a urinalysis, the nurse should assess the client for
A. kidney trauma.
B. sexually transmitted disease.
C. tumors.
D. infestation.

Back 310

B. sexually transmitted disease.

Front 311

An older adult client visits the clinic complaining of urinary incontinence.
The nurse should explain to the client that this is often due to
A. decreased urethral elasticity.
B. atrophy of the vaginal mucosa.
C. change in the vaginal pH.
D. decreased estrogen production.

Back 311

A. decreased urethral elasticity.

Front 312

A female client has scheduled a physical examination, including a Pap
smear. The nurse should instruct the client to
A. refrain from douching 48 hours before the examination.
B. bring in a urine sample for testing.
C. drink a large volume of fluid before the examination.
D. refrain from using talcum powder after her shower.

Back 312

A. refrain from douching 48 hours before the examination.

Front 313

The nurse is preparing to perform a speculum examination on an adult
woman. To lubricate the speculum before insertion, the nurse should use
A. sterile water.
B. K-Y jelly.
C. warm tap water.
D. petroleum jelly.

Back 313

C. warm tap water.

Front 314

The nurse is performing a speculum examination on an adult woman. The
nurse is having difficulty inserting the speculum because the client is
unable to relax. The nurse should ask the client to
A. bear down.
B. hold her breath.
C. use imagery to relax.
D. take a deep breath.

Back 314

A. bear down.

Front 315

The nurse is assessing the genitalia of a female client and detects a bulging
anterior ~vallin the vagina. The nurse should plan to refer the client to a
physician for
A. stress incontinence.
B. rectocele.
C. tumor of the vagina.
D. cystocele.

Back 315

D. cystocele.

Front 316

An older adult client visits the clinic for a gynecologic examination. The
client tells the nurse that she has been told that she has uterine prolapse.
The nurse should further assess the client for
A. stress incontinence.
B. cystocele.
C. a retroverted uterus.
D. diastasis recti.

Back 316

A. stress incontinence.

Front 317

While assessing the cervix of an adult client, the nurse observes a
yellowish discharge from the cervix. The nurse should further assess the
client for a/an
A. infection.
B. abnormal lesion.
C. positive pregnancy test result.
D. polyp.

Back 317

A. infection.

Front 318

While performing a gynecologic examination, the nurse observes small,
painful, ulcer-like lesions with red bases on the client's labia. The nurse
should refer the client to a physician for possible
A. herpes simplex virus infection.
B. syphilis.
C. lice.
D. herpes zoster virus infection.

Back 318

A. herpes simplex virus infection.

Front 319

While assessing the genitalia of a female client, the nurse observes moist
fleshy lesions on the client's labia. The nurse should refer the client to a
physician for possible
A. gonorrhea.
B. herpes simplex virus infection.
C. nabothian cysts.
D. genital warts.

Back 319

D. genital warts.

Front 320

During a gynecologic examination, the nurse observes that the client has a
yellow-green frothy vaginal discharge. The nurse should plan to test the
client for possible
A. Trichomonas uaginalis infection.
B. bacterial vaginosis.
C. atrophic vaginitis.
D. Chlamydia trachomatis infection.

Back 320

A. Trichomonas uaginalis infection.

Front 321

A client visits the clinic because she has missed one period and suspects
she is pregnant. While assessing the client, the nurse detects a sol~d,
mobile, tender, unilateral adnexal mass. The client's cervix is soft. The
nurse suspects that the client may be experiencing
A. normal pregnancy.
B. endometriosis.
C. pelvic inflammatory disease
D. ectopic pregnancy.

Back 321

D. ectopic pregnancy

Front 322

The corpora spongiosum extends distally to form the acorn-shaped
A. glans.
B. frenulum.
C. corona.
D. scrotum.

Back 322

A. glans.

Front 323

f a male client is uncircumcised, the glans of the penis is covered by the
A. epididymis.
B. frenulum.
C. corona.
D. foreskin.

Back 323

D. foreskin.

Front 324

The testes in the male scrotum are
A. joined with thc cjaculatory duct.
B. suspended by the spermatic cord.
C. able to produce progesterone.
D. the location of the vas deferens.

Back 324

B. suspended by the spermatic cord.

Front 325

The inguinal canal in a male client is located
A. just above and parallel to the inguinal ligament.
B. anteriorly above the symphysis pubis.
C. anterior to the external inguinal ring.
D. posterior to the superior iliac ring.

Back 325

A. just above and parallel to the inguinal ligament.

Front 326

During assessment of an elderly male client, the client tells the nurse that
he has had difficulty urinating for the past few weeks. The nurse should
refer the client to the physician for possible
A. inguinal hernia.
B. sexually transmitted disease.
C, impotence.
D. prostate enlargement.

Back 326

D. prostate enlargement.

Front 327

A 25-year-old client asks the nurse how often he should have a testicular
examination. After instructing the client about the American Cancer
Society's guidelines, the nurse determines that the client has understood the
instructions when he says he should have a testicular examination every
A. year.
B. 2 years.
C. 3 years.
D. 4 years.

Back 327

C. 3 years.

Front 328

A 45-year-old male client tells the nurse that he has had problems in
having an erection for the last couple of weeks but is "doing better now."
The nurse should explain to the client that
A. transient periods of erectile dysfunction are common.
B. impotence in males should be investigated.
C. transient impotence may be indicative of prostate enlargement.
D. inguinal hernias have been associated with transient impotence.

Back 328

A. transient periods of erectile dysfunction are common

Front 329

A male client tells the nurse that his occupation requires heavy lifting and
a great deal of strenuous activity. The nurse should assess the client for
A. signs and symptoms of prostate enlargement.
B. erectile dysfunction.
C. inguinal hernia.
D. urinary tract infection.

Back 329

C. inguinal hernia.

Front 330

During assessment of an adult client, which of the following lifestyle practices would indicate to the nurse that the client may be at high risk for HIVIAIDS? A client who
A. uses a condom on a regular basis.
B. has multiple female partners.
C. smokes marijuana occasionally.
D. has anal intercourse with other males.

Back 330

D. has anal intercourse with other males.

Front 331

During assessment of the genitalia of an adult male, the client has an
erection. The nurse should
A. explain to the client that this often happens during an examination.
B. cover the client's genitals and discontinue the examination.
C. allow the client time to rest before proceeding with the examination.
D. continue the examination in an unhurried manner.

Back 331

D. continue the examination in an unhurried manner.

Front 332

Before beginning the examination of the genitalia of an adult male client,
the nurse should
A. ask the client to empty his bladder.
B. tell the client that he will remain in a supine position.
C. ask the client to leave his shirt in place.
D. tell the client that he may leave his underwear in place.

Back 332

A. ask the client to empty his bladder.

Front 333

While assessing an adult male client, the nurse detects pimple-like lesions
on the client's glans. The nurse explains the need for a referral to the
client. The nurse determines that the client has understood the
instructions when the client says he may have
A. venereal warts.
B. herpes infection.
C. syphilis.
D. gonorrhea.

Back 333

B. herpes infection.

Front 334

While inspecting the genitalia of a male client, the nurse observes a
chancre lesion under the foreskin. The nurse has explained this
observation to the client. The nurse determines that the client understands
the need for a referral when the client says that chancre lesions are
associated with
A. herpesvirus.
B. syphilis
C. papillomavirus.
D. gonorrhea.

Back 334

B. syphilis

Front 335

A male client visits the clinic and tells the nurse that he has had a white
discharge from his penis for the past few days. The nurse should refer the
client to a physician for possible
A. urethritis.
B. gonorrhea.
C. herpes infection.
D. syphilis.

Back 335

A. urethritis.

Front 336

The nurse has assessed a male client and determines that one of the testes
is absent. The nurse should explain to the client that this condition is
termed
A. hypospadias.
B. hematocele.
C. cryptorchidism.
D. orchitis.

Back 336

C. cryptorchidism.

Front 337

The nurse is assessing the genitalia of an adult male client when he tells
the nurse that his testes are swollen and painful. The nurse should refer
the client to a physician for possible
A. cancer.
B. hydrocele.
C. epididyrnitis.
D. hematocele.

Back 337

C. epididyrnitis.

Front 338

Whiie transilluminating the scrota1 contents in a male adult client, the
nurse does not detect a red glow. The nurse should refer the client to a
physician for possible
A. spermatocele.
B. orchitis.
C. hydrocele.
D. varicocele.

Back 338

D. varicocele.

Front 339

The nurse suspects that a male client may have a hernia. The nurse should
further assess the client for
A. bruising at the site.
B. urinary tract infection.
C. cysts at the spermatic cord.
D. bowel sounds at the bulge.

Back 339

D. bowel sounds at the bulge.

Front 340

A male client tells the nurse that he has received a diagnosis of hernia. He
visits the clinic because he is nauseated and has extreme tenderness on the
left side. The nurse should
A. refer the client to an emergency room.
B. try to push the mass into the abdomen.
C. assess for a mass on the right side.
D. assess the client's vital signs.

Back 340

A. refer the client to an emergency room.

Front 341

A client visits the clinic and tells the nurse that she has had "runny
diarrhea" for 2 days. The nurse should assess the client for
A. gastrointestinal infection.
B. fecal impaction.
C. constipation.
D. hemorrhoids.

Back 341

A. gastrointestinal infection.

Front 342

A client visits the clinic and tells the nurse that his stools have been black
for the past 3 days. The nurse should assess the client for
A. gallbladder disease.
B. colitis.
C. polyps.
D. gastrointestinal bleeding.

Back 342

D. gastrointestinal bleeding.

Front 343

A client visits the clinic and tells the nurse that his stools have been pale
for the past 2 days and his skin has been itching. The nurse should refer
the client to a physician for possible
A. biliary disease.
B. cancer.
C. gastrointestinal infection
D. hemorrhoids.

Back 343

A. biliary disease.

Front 344

The nurse has instructed a S5-yesr-old male client about the need for a
stool test for occult blood. The nurse determines that the client
understands the instructions when he says the test should be performed
every
A. year.
B. 2 years.
C. 3 years.
D. 4 years.

Back 344

A. year.

Front 345

The nurse is planning a presentatio~lo n the topic of colorectal cancer to a
group of older adults. Which of the following should the nurse plan to
include in the presentation?
A. Colorectal cancer rates have steadily fallen over the past 30 years.
B. Eighty percent of those diagnosed with colorectal cancer are younger
than 50 years of age.
C. Diets high in fat and low in fiber are associated with colorectal cancer.
D. Colorectal cancer rates are decreasing outside the United States.

Back 345

C. Diets high in fat and low in fiber are associated with colorectal cancer.

Front 346

A 60-year-old male client asks the nurse about risk factors for prostate
cancer. The nurse should explain to the client that one possible risk
factor is
A. a high-carbohydrate diet.
B. exposure to sulfur.
C. genetic inheritance.
D. advanced age.

Back 346

D. advanced age.

Front 347

Cultural factors play an important role in the development of prostate
cancer in men. Which culture has the highest prostate cancer rate?
A. African American
B. White American
C. Italian
D. Japanese

Back 347

A. African American

Front 348

The nurse is planning to assess the anus and rectum of <In adult male
client. The nurse should position the client in a
A. right lateral position.
B. left lateral position.
C. prone position.
D. knee-chest position.

Back 348

B. left lateral position.

Front 349

The nurse is planning to inspect the anal area of an adult male client. TO
assess for any bulges or lesions, the nurse shoi~lda sk the client to
A. hold his breath.
B. breathe deeply through his mouth
C. breathe normally.
D. bear down.

Back 349

D. bear down.

Front 350

While assessing the anal area of an adult client, the nurse detects redness
and excoriation. The nurse determines that this sign is most likely due to
A. internal hemorrhoids.
B. an anorectal fistula.
C. a fungal infection.
D. previous surgery.

Back 350

C. a fungal infection.

Front 351

While assessi~lgth e anal area of an adult client, the nurse observes a
reddened swollen area covered by a small tuft of hair located midline on
the lower sacrum. The nurse should refer the client to a physic~anf or
possible
A. perianal abscess.
B. neurologic disorder.
C. pilonidal cyst.
D. anorectal fistula.

Back 351

C. pilonidal cyst.

Front 352

While assessing the anus of an adult client, the nurse detects the presence
of small nodules. The nurse should refer the client to a physician for
possible
A. polyps.
B. anorectal fistula.
C. hemorrhoids.
D. rectocele.

Back 352

A. polyps.

Front 353

While assessing the anus of an adult client, the nurse detects a peritoneal
protrusion. The nurse should refer the client to a physician for possible
A. anorectal fistula.
B. polyps.
C. prostate enlargement.
D. peritoneal metastasis.

Back 353

D. peritoneal metastasis.

Front 354

While examining the prostate gland of an older adult, the nurse detects
hard fixed nodules. The nurse should refer the client to a physician for
possible
A. prostate cancer.
B. benign prostatic hypertrophy.
C. acute prostatitis.
D. prostatocystitis.

Back 354

A. prostate cancer.

Front 355

One of the functions of a bone i s to
A. store fat.
B. produce secretions.
C. produce blood cells.
D. store protein.

Back 355

C. produce blood cells.

Front 356

Bones contain yellow marrow that i s composed mainly of
A. fat.
B. protein.
C. cartilage.
D. carbohydrates.

Back 356

A. fat.

Front 357

The external covering of the bone that contains osteoblasts and blood
vessels is termed the
A. cartilage.
B. synovial membrane.
C. connective tissue.
D. periosteum.

Back 357

D. periosteum.

Front 358

Skeletal muscles are attached to bones by
A. tendons.
B. cartilage.
C. fibrous connective tissue.
D. ligaments.

Back 358

A. tendons.

Front 359

Joints may be classified as cartilaginous, synovial, or
A. articulate.
B. flexible.
C. immobile.
D. fibrous.

Back 359

D. fibrous.

Front 360

Bones in synovial joints are joined together by
A. cartilage.
B. ligaments.
C. tendons.
D. periosteal tissue.

Back 360

B. ligaments.

Front 361

When the nurse moves the client's arm away from the midline of the body,
the nurse is performing
A. adduction.
B. external rotation.
C. retraction.
D. abduction.

Back 361

D. abduction.

Front 362

When the nurse moves a client's leg upward, the nurse is performing
A. supination.
B. external rotation.
C. eversion.
D. internal rotation.

Back 362

A. supination.

Front 363

The subacromial bursae are contained in the
A. temporomandibular joint.
B. shoulder joint.
C. elbow joint.
D. wrist joint.

Back 363

B. shoulder joint.

Front 364

Articulation between the head of the femur and the acetabulum
is in the
A. knee joint.
B. tibial joint.
C. ankle joint.
D. hip joint.

Back 364

D. hip joint.

Front 365

A client visits the clinic and tells the nurse that she has joint pain in her
hands, especially in the morning. The nurse should assess the client
further for signs and symptoms of
A. arthritis.
B. osteoporosis.
C. carpal tunnel syndrome.
D. a neurologic disorder.

Back 365

A. arthritis.

Front 366

A client with insulin-dependent diabetes visits the clinic and complains of
painful hip joints. The nurse should assess the client carefully for signs
and symptoms of
A. arthritis.
B. gait difficulties.
C. osteomyelitis.
D. scoliosis.

Back 366

C. osteomyelitis.

Front 367

A female client visits the clinic and tells the nurse that she began menarche
at the age of 16 years. The nurse should instruct the client that she is at a
higher risk for
A. osteoporosis.
B. osteomyelitis.
C. rheumatoid arthritis.
D. lordosis.

Back 367

A. osteoporosis.

Front 368

The nurse is planning a presentation on osteoporosis to a group of high
school students. Which of the following should the nurse plan to include
in the presentation?
A. Bone density rises to a peak at age 50 for both sexes.
B. Bone density in the Asian population is higher than in the white
population.
C. Moderate strenuous exercise tends to increase bone density.
D. Approxinately 5 million fractures in the United States are due to osteoporosis.

Back 368

C. Moderate strenuous exercise tends to increase bone density.

Front 369

The nurse is caring for an adult client who is in a cast because of a
fractured arm. To promote healing of the bone and tissue, the nurse
should instruct the client to eat a diet that is high in
A. whole grains.
B. vitamin B.
C. vitamin E.
D. vitamin C.

Back 369

D. vitamin C.

Front 370

An adult client tells the nurse that he ears sardines every day. The nurse
should instruct the client that a diet high in purines can contribute to
A. gouty arthritis.
B. osteomalacia.
C. bone fractures.
D. osteomyelitis.

Back 370

A. gouty arthritis.

Front 371

A client tells the nurse that his grandmother had a diagnosis of
osteomalacia. The nurse should instruct the client that to decrease the risk
factors for osteomalacia, the clients should have adequate amounts of
A. vitamin E.
B. riboflavin.
C. beta-carotene.
D. vitamin D.

Back 371

D. vitamin D.

Front 372

The nurse is preparing ro perform a musculoskeletal examination on an
adult client. The nurse has explained the examination procedure to the
client. The nurse determines that the client needs further instructions
when the client says
A. "You will be asking me to change positions often."
B. "You'll be comparing bilateral joints."
C. "You'll be assessing the size and strength of my joints."
D. "You'll continue with range of motion even if I have discomfort."

Back 372

D. "You'll continue with range of motion even if I have discomfort."

Front 373

While assessing muscle strength in an older adult client, the nurse
determines that the client's knee joint has a rating of 3 and exhibits active
motion against gravity. The nurse should document the client's muscle
strength as beinglhaving
A. normal.
B. slight weakness.
C. average weakness.
D. poor range of motion.

Back 373

C. average weakness.

Front 374

While assessing an adult client's jaw, the nurse hears a clicking popping
sound, and the client expresses pain in the joint. The nurse should further
assess the client for
A. arthritis.
B. TMJ dysfunction
C. bruxism.
D. previous fracture.

Back 374

B. TMJ dysfunction

Front 375

While examining the spine of an adult client, the nurse notes that the
client has a flattened lumbar curvature. l'lie nurse should refer the client
to a physician for possible
A. herniated disc.
B. scoliosis.
C. kyphosis.
D. cervical disc degeneration.

Back 375

A. herniated disc.

Front 376

The nurse is assessing the spine of an adult client and detects lateral
curvature of the thoracic spine with an increase in convexity on the left
curved side. The nurse suspects that the client is experiencing
A. lordosis.
B. arthritis.
C. kyphosis.
D. scoliosis.

Back 376

D. scoliosis.

Front 377

A client visits the clinic and tells the nurse that he has had lower back pain
for the past several days. To perform Las2gue's test, the nurse should ask
the client to
A. bend backward toward the nurse.
B. lean forward and touch his toes.
C. twist the shoulders in both directions.
D. lie flat and raise his leg to the point of pain.

Back 377

D. lie flat and raise his leg to the point of pain.

Front 378

An older adult client visits the clinic and tells the nurse that she has had
shooting pains in both of her legs. The nurse should assess the client for
signs and symptoms of
A. herniated intervertebral disc.
B. rheumatoid arthritis.
C. osteoporosis.
D. metastases.

Back 378

A. herniated intervertebral disc

Front 379

While assessing the range of motion in an adult client's shoulders, the
client expresses pain and exhibits limited abduction and muscle weakness.
The nurse plans to refer the client to a physician for possible
A. rotator cuff tear.
B. nerve damage.
C. cervical disc degeneration.
D. tendonitis.

Back 379

A. rotator cuff tear.

Front 380

While assessing an older adult client, the client complains of chronic pain
and severe limitation of all shoulder movements. The nurse should refer
the client to a physician for possible
A. rotator cuff tendonitis.
B. rheumatoid arthritis.
C. calcified tendinitis.
D. chronic bursitis.

Back 380

C. calcified tendinitis.

Front 381

The nurse is examining an adult client's range of motion in the shoulders.
The client is unable to shrug her shoulders against resistance. The nurse
suspects that the client has a lesion of cranial nerve
A. VIII.
B. IX.
C. X.
D. XI.

Back 381

D. XI.

Front 382

While assessing the elbow of an adult client, the client complains of pain
and swelling. The nurse should further assess the client for
A. arthritis.
B. ganglion cyst.
C. carpal tunnel syndrome.
D. nerve damage.

Back 382

A. arthritis.

Front 383

While reviewing a client's chart before seeing the client for the first rime, -
the nurse notes that the client has a diagnosis of Dupuytren's contracture.
The nurse anticipates that the client will exhibit
A. inability to turn the wrists.
B. ulnar deviation of the hands.
C. flexion of the distal interphalangeal joints.
D. inability to extend the ring and little finger.

Back 383

D. inability to extend the ring and little finger

Front 384

While assessing the musculoskeletal system of an adult client, the nurse
observes hard painless nodules over the distal interphalangeal joints. The
nurse should document the presence of
A. osteoarthritis.
B. bursitis.
C. tendonitis.
D. rheumatoid arthritis.

Back 384

A. osteoarthritis.

Front 385

A client visits the clinic and complains of wrist pain. To perform Phalen's
test, the.nurse should ask the client to
A. move the hand inward with the wrists straight.
B. place both palms on the examination table.
C. flex both wrists against resistance.
D. place the backs of both hands against each other.

Back 385

D. place the backs of both hands against each other.

Front 386

While assessing an adult client, the nurse tests the client for Tinel's sign.
The nurse should instruct the client that numbness or tingling may
indicate
A. arthritis.
B. carpal tunnel syndrome.
C. tenosynovitis.
D. crepitus.

Back 386

B. carpal tunnel syndrome.

Front 387

While assessing the musculoskeletal system of an adult client, the nurse
detects tenderness, warmth, and a boggy consistency of the client's knee.
The nurse should refer the client to a physician for possible
A. torn meniscus.
B. malignancy.
C. fracture.
D. synovitis.

Back 387

D. synovitis.

Front 388

A client visits the clinic and complains of pain in his knees. The nurse
explains that a ballottement test will be performed. To perform the
ballottement test, the nurse should
A. place the left thumb and index finger on either side of the patella.
B. use the ball of the hand to firmly stroke the medial side of the knee.
C. press the lateral side of the knee and inspect for swelling.
D. palpate for tenderness 10 centimeters above the patella.

Back 388

A. place the left thumb and index finger on either side of the patella.

Front 389

While assessing an older adult client, the nurse notes decreased range of
motion and crepitation as the client tries to bend his knees to his chest.
The nurse determines that the client is most likely experiencing
A. flexion contractures.
B. signs of aging.
C. osteoarthritis.
D. genu valgum.

Back 389

C. osteoarthritis.

Front 390

A client visits the clinic and tells the nurse that after playing softball
yesterday, he thinks his knee is "locking up." The nurse should perform
the McMurray7s test by asking the client to
A. move from a standing to a squatting position.
B. raise his leg while in a supine position.
C. bend forward while trying to touch the toes.
D. flex the knee and hip while in a supine position.

Back 390

D. flex the knee and hip while in a supine position.

Front 391

While assessing the feet of an adult client, the nurse notes that the client's
great toes are deviated, with overlapping of the second toes. The client
states that there is pain on the medial side. The nurse should refer the
client to a physician for possible
A. hallux valgus.
B. pes planus.
C. pes cavus.
D. verruca vulgaris.

Back 391

A. hallux valgus.

Front 392

While reviewing a client's chart before seeing the client for the first time,
the nurse notes that the client has a diagnosis of pes planus. The nurse
anticipates that the client has
A. high arches.
B. bunions.
C. calluses.
D. flat feet.

Back 392

D. flat feet.

Front 393

While assessing the feet of an older adult client the nurse observes that the
metatar~ophalan~ejaoli nt to the client's great toe is tender, reddened, and
painful. The nurse should refer the client to a physician for possible
A. bunions.
B. corns.
C. hammer toe
D. gouty arthritis.

Back 393

D. gouty arthritis.

Front 394

While assessing the feet of an adult client, the nurse observes
hyperextension of the metatarsophalangeal joint with flexion at the
proximal interphalangeal joint on the client's second toes. The nurse
should refer the client to a physician for possible
A. hammer toes.
B. gouty arthritis.
C. calluses.
D. hallux valgus.

Back 394

A. hammer toes.

Front 395

While assessing the feet of an adult client, the nurse observes tiny dark
spots under a painful callus on the client's foot. The nurse should
document the presence of
A. corns.
B. bunions.
C. plantar warts.
D. gouty arthritis.

Back 395

C. plantar warts.

Front 396

The cerebrospinal fluid cushions the central nervous system (CNS), provides
nourishment to the CNS, and
A. transmits impulses.
B. coats the brain.
C. regulates heart rate.
D. removes wastes.

Back 396

D. removes wastes.

Front 397

The cerebrum is divided into right and left hemispheres, which are joined
together by the
A. corpus callosum.
B. diencephalon.
C. medulla oblongata.
D. pons.

Back 397

A. corpus callosum.

Front 398

The portion of the brain that rims the surfaces of the cerebral hemispheres
forming the cerebral cortex is the
A. gray matter.
B. cerebellum.
C. diencephalon.
D. brainstem.

Back 398

A. gray matter.

Front 399

The diencephalon of the brain consists of the
A. pons and brainstem.
B. medulla oblongata and cerebrum.
C. cerebellum and midbrain.
D, thalamus and hypothalamus.

Back 399

D, thalamus and hypothalamus.

Front 400

T he hypothalamus is responsible for regulating
A. sleep cycles.
B. nerve impulses.
C. memory.
D. eye reflexes.

Back 400

A. sleep cycles.

Front 401

Sensations of temperature, pain, and crude and light touch are carried
by way of the
A. extrapyramidal tract.
B. corticospinal tract.
C. spinothalamic tract.
D. posterior tract.

Back 401

C. spinothalamic tract.

Front 402

The cranial nerve that has sensory fibers for taste and fibers that result in
the "gag reflex" is the
A. vagus.
B. hypoglossal.
C. trigeminal.
D. glossopharyngeal.

Back 402

D. glossopharyngeal.

Front 403

The nurse is assessing an older adult client when the client tells the nurse
that she has experienced transient blind spots for the last few days. The
nurse should refer the client to a physician for possible
A. vagus nerve damage.
B. cerebral vascular accident.
C. spinal cord compression.
D. Parkinson's disease.

Back 403

B. cerebral vascular accident.

Front 404

The nurse is planning a presentation to a group of adults on the topic of
cardiovascular accidents. Which of the following should the nurse plan to
include in the teaching plan?
A. Strokes are the number one cause of death in the United States.
B. Smoking and high cholesterol levels are risk factors for CVA.
C. Clients who smoke while taking oral contraceptives are not at higher risk
D. Postmenopausal women taking estrogen are at greater risk for CVA.

Back 404

B. Smoking and high cholesterol levels are risk factors for CVA.

Front 405

The nurse is caring for a client during the immediate postoperative period
after abdominal surgery. While performing a "neuro check" the nurse
should assess the client's
A. sensation in the extremities.
B. deep tendon reflexes.
C. ability to speak.
D. recent memory.

Back 405

A. sensation in the extremities.

Front 406

The nurse is preparing to percuss a client's reflexes in his arms. To use the
reinforcement technique, the nurse should ask the client to
A. clench his law.
B. stretch the opposite arm.
C. hold his neck toward the floor,
D. straighten his legs forward.

Back 406

A. clench his law.

Front 407

The Glasgow Coma Scale measures the level of consciousness in clients
who are at high risk for rapid deterioration of the nervous systetn. A
score of 13 indicates
A. deep coma.
8. severe impairment.
C, no verbal response.
D. some impairment.

Back 407

D. some impairment.

Front 408

A client visits the clinic and tells the nurse that he has not been feeling
very well. The nurse observes that the client's speech is slow, the client has
a disheveled appearance, and he maintains poor eye contact with the
nurse. The nurse should further assess the client for
A. depression.
B. delirium.
C. hallucinations.
D. schizophrenia.

Back 408

A. depression.

Front 409

While assessing the neurologic system of a confused older adult, the nurse
observes that the client is unable to recall past events. The nurse suspects
that the client may be exhibiting signs of
A. depression.
B. anxiety.
C. attention deficit disorder.
D. cerebral cortex disorder.

Back 409

D. cerebral cortex disorder.

Front 410

The nurse is assessing the neurologic system of an adult client. To test the
client's use of memory to learn new information, the nurse should ask the
client
A. "What did you have for breakfast?"
B. "How old were you when you began working?"
C. "Can you repeat rose, hose, nose, clothes?"
D. "Can you repeat brown, chair, textbook, tomato?"

Back 410

D. "Can you repeat brown, chair, textbook, tomato?"

Front 411

While assessing the pupils of a l~ospitalizcd adult client, the nurse
observes that the client's pupils arc dilated to 6 centinieters. The nurse
suspects that the client is exhibiting signs ot
A. oculomotor nerve paralysis.
B. damage to the pons.
C. alcohol abuse.
D. cocaine abuse.

Back 411

A. oculomotor nerve paralysis

Front 412

The nurse is assessing the neurologic system of an adult client. To test the
client's motor function of the facial nerve, the nurse should
A. ask the client to purse the lips.
B. ask the client to open the mouth and say "ah."
C. note tlie presence of a gag reflex.
D. observe the client s\vallo\v a sip of water.

Back 412

A. ask the client to purse the lips.

Front 413

The nurse is assessing tlie neurologic system of n client who has spastic
muscle tone. The nurse should explain to the client that spastic muscle
tone is associated with impairment to the
A. extrapyramidal tract.
B. spinothalamic tract.
C. posterior columns.
D. corticospinal tract.

Back 413

D. corticospinal tract.

Front 414

The nurse is preparing to perform the Rosiberg test on an adult male
cllent. The nurse should instruct the cllent to
A. squat down as far as he is able to do so.
B. keep his eyes open while he bends at the knees.
C. stand erect with arms at the sides and feet together.
D. touch the tip of his nose with his finger.

Back 414

C. stand erect with arms at the sides and feet together.

Front 415

The nurse is planning to test position sensation in an adult female client.
To perform this procedure, the nurse s l ~ ~ ~asikl dth e client to close her
eyes while the nurse moves tlie client's
A. arm away from the body.
B. toes up or down.
C. hand forward and then backward.
D. leg away from the body.

Back 415

B. toes up or down.

Front 416

While assessing the Achilles reflex in an 84-year-old client, the nurse
observes that the Achilles reflex is difficult to elicit. The nurse should
A. refer the client to a physician for further evaluation.
B. ask the client about injuries to the feet.
C. determine whether the client is having any pain in the feet.
D. document the finding in the client's record.

Back 416

D. document the finding in the client's record.

Front 417

While assessing the plantar reflex of an adslt client, the nurse observes a
positive Babinsk~r eflex. The nurse suspects that the client may be
exhibiting signs of
A. meningeal irritation.
B. diabetes mellitus.
C. drug intoxication.
D. lower motor neuron lesions.

Back 417

C. drug intoxication.

Front 418

The best approach to use when perbraling a total physical examination on
a client is
A. a toe-to-head integrated assessment of body systems.
B. a head-to-toe integrated assessment of body systems.
C. a total body system approach examining each body system individually.
D. any approach that is convenient for you and the client.

Back 418

B. a head-to-toe integrated assessment of body systems.

Front 419

Before beginning a physical assessment it is important for the nurse to
A. explain to the client in detail how each body system will be assessed.
B. explain to the client the purpose of every physical assessment technique
you will be using.
C. acquire your client's verbal permission to perform the physical examination.
D. acquire your client's written pernlission to perfor111 the physical
examination.

Back 419

C. acquire your client's verbal permission to perform the physical examination.

Front 420

Two body systems that may be logically integrated and assessed at the same
time are the
A. eye and ear exams.
B. eye exam and cranial nerves 11, 111, IV, and VI.
C. ear exam and cranial nerves IV, V1, and VIII.
D. ear and nose exams.

Back 420

B. eye exam and cranial nerves 11, 111, IV, and VI.

Front 421

Examination of the skin should be
A. integrated throughout the head-to-toe examination.
B. completed at the beginning of the physical assessment before proceeding
to other parts of the exam.
C. performed at the very end of the physical assessment.
D. integrated and completed only with the musculoskeleteal examination.

Back 421

A. integrated throughout the head-to-toe examination.

Front 422

The physical declines of aging often first become noticeable when
A. approxin~ately5 0% of function is lost.
B. the person is at least 75 years old.
C. acute or chronic illness places excessive demands on the body.
D. cognitive declines become significant.

Back 422

C. acute or chronic illness places excessive demands on the body.

Front 423

X benign skin lesion con~monlys een in the aged is
A. squalnous cell carcinoma.
B. shingles.
C. actinic keratosis.
D. lentigenes.

Back 423

D. lentigenes.

Front 424

Diminished vibratory sensations and slowed motor responses in advanced
age result in
A. stiffness and rigidity.
B. paresthesia.
C. postural instability.
D. tremors.

Back 424

C. postural instability.

Front 425

A sign of infection in the elder that is more common than fever is
A. pain
B. confusion.
C. diarrhea.
D. cough.

Back 425

B. confusion.

Front 426

A neurologic clin~igea ssociated with normal aging is
A. loss of long-tern~m emory.
B. a decrease In reaction time.
C. swaying or shuffling gait.
D. a significant decline in judgment and cognition.

Back 426

B. a decrease In reaction time

Front 427

A risk factor for sinusitis in the frail elderly is
A. a nasogastric feeding tube.
B. an accumulation of ear wax.
C. decreased ability to detect odors.
D. conductive hearing loss.

Back 427

A. a nasogastric feeding tube.

Front 428

Common signs or symptoms of disease in the oldest-old include all of the
below except
A. weakness.
B. confusion.
C. falls.
D. fever.

Back 428

D. fever.

Front 429

Any new onset of incontinence in the frail elder should be investigated for
A. prostatitis.
B. stroke.
C. fecal impaction.
D. urinary tract infection.

Back 429

D. urinary tract infection.

Front 430

An objective assessnlent that is frequently indicated when the subjective
assessment reveals a history of falling is
A. a 24-110~1fro od diary.
B. a Get Up and Go test.
C. a tonometry exam.
D. palpation of the joints for crepitus.

Back 430

B. a Get Up and Go test.

Front 431

A gastrointestinal problenl that often requires emergency treatment in the
frail elder is
A. lactose intolerance.
B. hiatal herilia
C. diverticulitis.
D. Crohn's disease.

Back 431

C. diverticulitis.

Front 432

To cornpe~isatef ur a stooped poslure atid less flexible knee, hip, and
shoulder joints, the elderly person often walks
A. with a waddling type of gait.
B. with one leg slightly dragging behind the other.
C. with the feet farther apart and the knees slightly bent.
D. with a slight swaying side-to-side motion.

Back 432

C. with the feet farther apart and the knees slightly bent.

Front 433

A common sign or symptom of depression in the elderly is
A. rambling or incoherent speech.
B. illusion or hallucinations.
C. insomnia.
D. cognitive impairment or pseudodementia.

Back 433

D. cognitive impairment or pseudodementia.

Front 434

A key area to assess in older adults with chronic respiratory or cardiac
problems and some constant degree of dyspnea is
A. nutritional deficiency.
B. dysphagia.
C. the degree to which dyspnea affects daily function.
D. a possible history of in~munosuppression.

Back 434

C. the degree to which dyspnea affects daily function.

Front 435

A characteristic sign of delirium is
A. a significant decline in memory.
B. a chronic low mood.
C. a rapid decline in level of alertness.
D. disorientation to self.

Back 435

C. a rapid decline in level of alertness.

Front 436

All of the following are accurate signs of dehydration in the frail elder
except
A. a furrowed tongue.
B. tenting of the skin when pinched.
C. dry warm skin.
D. sunken eyes.

Back 436

B. tenting of the skin when pinched.

Front 437

Signs of arterial insufficiency in the very old include all of the following
except
A. paleness of the leg when elevated.
B. dusky or mottled appearance of the leg in a dependent position.
C. hair loss on the skin.
D. cool, thin, shiny skin.

Back 437

C. hair loss on the skin.