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40 Cards in this Set
- Front
- Back
- 3rd side (hint)
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When using assessment equipment that will touch the client, what should the nurse do before conducting the assessment. A. Rent the equipment to prevent infection B. Draw pictures of the anatomy to be assessed C. Warm the equipment with hands or warm water D. Sterilize any parts that will contact the client's skin |
Warm the equipment with hands or warm water |
Page 247 |
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The nurse palpating the skin of a client documents a firm 1.5 CM Mass on the lower right leg. What type of skin lesion does this describe A. Vesicle B. Macula C. Wheel D. Nodule |
nodule |
Page 243 |
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When assessing the abdomen, which assessment technique is used last A. Palpation B. Auscultation C. Percussion D. Inspection |
Palpation |
Page 250 |
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The nurse, after receiving a report on assigned clients, begins assessments of the clients. What is the primary purpose of assessing clients? A. By completing assessment, the nurse is able to expand nursing Knowledge and Skills B. The nurses able to identify actual and potential health problems of the client C. This provides a basis for evidence-based nursing care D. Assessing the clients helps to identify the nurse's role in healthcare |
The nurse is able to identify actual and potential health problems of the client |
Page 247 |
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A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rhinne test no thanks for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork? A. On the center of the head B. On the mastoid area C. Near the ear canal D. Behind the clients head |
On the mastoid area |
Page 240 |
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The nurse has finished assessing a newly admitted six-month-old First Nations client. Which clinical findings should be immediately reported to the health care provider? A. A blue-black macular area over the sacral area B. The abdomen appearing large in relation to the pelvis C. The anterior fontanelle bulging when the client cries D. Circumoral cyanosis when the client is at rest |
Circumoral cyanosis when the client is at rest |
Page 243 |
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The nurse is preparing to assess a client's abdomen arrange the steps of the assessment in the correct order: palpation, inspection, auscultation, percussion |
Inspection, auscultation, percussion, palpation |
Page 250 |
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A nursing student is having difficulty hearing and interpreting sounds during the auscultation phase of chest assessment. What should the student do to improve the ability to discern between different sounds during auscultation? A. a colleague listen simultaneously with a different stethoscope B. Review the anatomy, physiology, and pathophysiology involved in respiratory diseases C. Practice auscultating on as many healthy and Ill individuals as possible D. Perform a thorough percussion assessment prior to auscultation |
Practice auscultating on as many healthy and Ill individuals as possible |
Page 235 |
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A nurse is assessing a client's respiratory system and made the following entry in the client's medical record:" crackles auscultated to lower lungs Fields bilaterally. " this abnormal assessment finding indicates: A. What's the movement of air through a narrow passage B. Which is hypoventilation C. The presence of fluid in the alveoli D. Accumulation of carbon dioxide in the alveoli |
The presence of fluid in the alveoli |
Page 248 |
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A nurse is teaching a young female client about breast cancer prevention. The client asked at what age she needs to begin having mammograms. What is the nurses best response? A. why do you want to know? Do you have a history of breast or ovarian cancer in your family? B. Your physician will decide when it's best for you to begin having mammograms based on your family history. C . According to the American and Canadian Cancer Society, your first mammogram should be done at the age of 40 and then yearly after that. D. Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s. |
According to the American and Canadian Cancer society's, your first mammogram should be done at age 40 and then nearly after that |
Page 245 through 246 |
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A nurse is admitting a new client to the hospital needs to determine the client's needs and current problems. What is a priority action of the nurse? A. Review the client's past medical records B. Contact the health care provider C. Assist a client with activities of daily living D . Complete assessment |
Complete an assessment |
Page 16 |
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A nurse is planning to obtain a weight on an obese client who has a history of Falls. What is the best way to obtain the clients weight? A. Use an electronic bed scale B. Transfer the client to a chair scale C. Assist the client to stand on a scale at the bedside D. Delegate this task to the assistive personnel |
Use an electronic bed scale |
Page 236 |
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A nurse is preparing to complete an assessment on a client with a history of heart disease. Which will the nurse use to begin the assessment? A. percussion B. Palpation C. Auscultation D. Inspection |
Inspection |
Pace 234 to 235 |
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During an abdominal assessment, the nurse is unable to hear bowel sounds in the client's right lower quadrant. How long should the nurse listen before documenting absent bowel sounds? A. 5 minutes B. 30 seconds C. 8 minutes D. One minute |
5 minutes |
Page 251 |
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A nurse is preparing to assess the integumentary system for texture, temperature, moisture, and edema. Which assessment technique will the nurse use? A. Auscultation B. Percussion C. Palpation D. Inspection |
Palpation |
Page 234 |
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A nurse is performing a whisper test on an elderly client. How should the nurse complete this assessment? A. Place headphones on the client to listen for recorded sounds B. Place a vibrating tuning fork on top of the clients head C. Send two feet behind and to the side of the client D. Staying in front of the client and have them close their eyes |
Stand 2 feet behind and to the side of the client |
Page 241 |
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A nurse is assessing the pupillary response of a client brought into the emergency department with a head injury. Both peoples around and react to light. What can the nurse interpret about the client's neurological status based on these data? A. Brain function is within normal limits B. The client has 20-20 vision C. Cranial nerve number one is intact D. The client should be referring to an ophthalmologist |
Brain function is within normal limits |
Page 239 |
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The nurse is assessing the legs of a client and notes fairly normal Contour with a 4 mm indentation when pressing on the shin and calf of each leg. How should the nurse interpret these findings? A. Trace edema B. 2 + pitting edema C. 1 + pitting edema D. Brawny edema |
2 + pitting edema |
Page 249 |
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A nurse is preparing to assess a client with abdominal pain. Which statement is most appropriate for the nurse to use to gain cooperation from the client? A. I am going to examine your abdomen B. Let me explain what I am going to do and how you can help C. I need to report what is going on to your health care provider. Can I look at your abdomen? D. Open your shirt, I need to look at your abdomen |
Let me explain what I am going to do and how you can help |
Page 407 |
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The nurse is assessing the skin of a veteran who has returned from deployment overseas. Which response by the nurse reflects the best strategy to gain cooperation of the client? A. I need to look at your skin to see if you have any problems B. May I look at your skin to determine if there are any issues C. Take off your clothes so I can look at your skin D. I am going to look at your skin now |
May I look at your skin to determine if there are any issues |
Page 386 |
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During the admission assessment of a new client, the nurse is preparing to assess the client's thyroid gland. How should the nurse perform this assessment? A. Stand behind the client and palpate the sides of the trachea B. Lightly percuss slightly off midline over the clients trachea C. Observe the midline of the client's neck while asking him to Bear Down D. Auscultate over the clients trachea while asking the client to hold his breath |
Stand behind the client and palpate the sides of the trachea |
Page 244 |
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A nurse is preparing to examine the breast of a client. And what position should the nurse place the client? A. Prone B. Lithotomy C. Standing D. Dorsal recumbent |
Dorsal recumbent |
Page 245 |
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A nurse is inspecting the ear canals and tympanic membrane of an 18 month old child. How would the p i n n a move to achieve Better visualization? A. There is no need to move the pinna B. Pull the pinna parallel to the side of the head C. Gently pull the pinna down and back D. Gently pull the pinna up and back |
Gently pull the pinna down and back |
Page 240 |
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While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds? A. Narrowed small air passages B. Moisture and air passages C. A narrowing of the upper Airway D. Air in the lungs |
Moisture in air passages |
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Which framework is used during the focused assessment? A. Body systems framework B. Functional Health assessment C. Head to toe framework D. Conceptual framework |
Body systems framework |
Page 237 |
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To assess a client's she will accommodation, the nurse has the client: A. Look straight ahead with one eye covered B. Stand 20 feet from a Snellen chart C. Look at a close object, then look at a distant object D. Sit still while a penlight is shined at the pupil |
Look at a close object, then at a distant object |
Page 239 |
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To access an adult clients hearing, the nurse performs a Rinne test by activating the tuning fork and placing it first at the : A. Mastoid process B. Affected ear C. Front of the ear D. Top of the head |
Mastoid process |
Page 240 |
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The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment? A. Blowing, Hollow sounds auscultated over the larynx B. An anteroposterior two lateral ratio of 1 to 2 C. Auscultation of short, high pitch popping sound during inspiration D. Palpation of muscle symmetry over the posterior thorax |
Auscultation of short, high-pitched popping sounds during inspiration |
Page 248 |
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Which action best allows the nurse to assess a client's pupillary accommodation? A. Using an ophthalmoscope, check the clients red reflex B. Ask the client to focus on a finger and move the client's eyes through the six cardinal positions of gaze C. Ask the client to focus on an object as it is brought closer to the nose D. Ask the client to read the smallest possible line of letters on the Snellen chart |
Ask the client to focus on an object as it is brought closer to the nose |
Page 239 |
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Which statement accurately represents a characteristic of a third or fourth heart sound? A. S3 is considered normal in children and young adults and abnormal in middle-aged and older adults B. S4 is the fourth heart sound, represented by Lub dub dee C. S3 is best heard with the cystoscope bell at the mitral area, when the client is laying on the right side D. S4 is considered normal in children and adults but abnormal in older adults |
S3 is considered normal in children and young adults and abnormal in middle-aged and older adults |
Page 246 |
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The client has requested a translator so that she can understand the questions at the nurses asking during the client interview. What is important when working with the client translator? A. Talk directly to the translator facilitate the transfer of information B. It is always okay to not use a translator if a family member can do it C. Talk loudly helps the translator and the client understand the information better D. Translators may need additional explanations of medical terms |
Translators may need additional explanations of medical |
Page 79 |
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A nurse is preparing to complete a physical assessment on an older adult client with a history of emphysema. What is the nurses most appropriate action? A. Lie the client supine on the exam table B. Begin with auscultation of the lungs C. Assist a client to a sitting position D. Dim the lights to avoid eye strain |
Assist a client to a sitting position |
Page 234 |
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A nurse is caring for a post-operative client 1 day after coronary artery bypass surgery. Which nursing interventions demonstrate the skill of assessment? Select all that apply. A. Reviewing morning lab results B. assisting the client to sit up in a chair C. Taking the client's blood pressure D. Helping the client to bathe and brush their teeth E. Inspecting the abdominal incision |
One inspecting the abdominal incision. To taking the client's blood pressure. 3 reviewing morning lab results. |
Page 16 |
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The nurse is preparing to assess a client's visual acuity. How should the nurse proceed? A. Ask the client to read the print on a handheld Jagger card B. Perform the confrontation test C. Use a pen light to determine if the pupils are perrla D. Use the Snellen chart position at 20 feet
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Use the Snellen chart position at 20 feet |
Page 238 to 239 |
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Which technique should the nurse use when assessing the radial pulse of a client with a history of atrial fibrillation? A. Palpate the pulse for 2 minutes B. Palpating the pulse for 10 seconds and multiply by 6 C. Palpate the pulse for 15 seconds and X bye 4 D. Palpate the pulse for 1 minute
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Palpating the pulse for 1 minute |
Page 248 |
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The nurse is auscultating the anterior chest of a client in hears gurgles. What is the nurses appropriate action? A. Notify the healthcare provider B. Document the findings C. Ask a client the cough and auscultate the anterior chest again D. Ask the client if they have any difficulty breathing
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Ask the client to cough and auscultate the anterior chest again |
Paige 247-248 |
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While giving a client a bath, the nurse observes the color of the client's skin as having a yellowish tinge. Which question would the nurse ask the client? A. Have you had diarrhea or constipation lately B. Do you use acetaminophen or drink alcohol C. How much caffeine do you drink per day D. How long have you had these spots |
Do you use acetaminophen or drink alcohol |
Page 393 |
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A nurse must perform an integumentary inspection on a client. Which statement most effectively explains why the nurse will be assessing the client's skin? A. I am inspecting your skin to get a baseline of your skin into check if any conditions require treatment B. I will be inspecting your skin to report findings to your healthcare provider C. I will be inspecting your skin to determine if there are any conditions requiring treatment D. I'm inspecting your skin to get a baseline of your skin status |
I am inspecting your skin to get a baseline of your skin and to check if any conditions require treatment |
Page 244 |
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The nurse is performing a head and neck assessment for a client when inspecting the face, the nurse notes that the skin, sclera, and mucous membranes appear yellowish. In the electronic medical record the nurse chooses which drop down box selection to document this finding? A. Jaundice B. Cyanosis C. Erythema D. Pallor
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jaundice |
Page 243 |
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A nurse is assessing the abdomen of a newly admitted client. Place in order the steps of assessing the abdomen. Use all options. 1 auscultation. To palpation. 3 inspection. For percussion. |
Inspection, auscultation, percussion, palpation. |
Page 251 |
