1.The nurse is assessing a client in the emergency department (ED) who complains of right lower quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign. Based on the client’s assessment data, which conditions does the nurse suspect?
a.Peritonitis b.Appendicitis Colescistitis Abdominal Pain.
2.The nurse is discharging a client with osteoarthritis. Which points will the nurse include in this client’s discharge teaching? a.Obesity increases the risks of bone, muscle, and joint disorders. b.Musculoskeletal health is influenced by the diet. c.Exercise is important in the prevention of osteoarthritis d. Smokind and alcohol contribute e. As the condition progresses the hands may develop.
3. A client experienced blood loss from surgery. What is the impact of this blood loss on the kidney’s functioning? A. Stimulation of the kidneys to produce erythropoietin b. No impact in the kidney function.
4. A toddler-age client is brought to the emergency department (ED) with difficulty breathing. The healthcare provider diagnoses the client with epiglottitis. Which assessment data collected by the nurse are consistent with this diagnosis?
Standard Text: Select all that apply.
a. Oxygen saturation level is 85% on room air. b. Stridor is audible without stethoscope. c.Temperature is 103.7°F. d.Apical heart rate is 72 beats per minute. e.Respiratory rate is 22 per minute.
5 The nurse is observing a client’s ambulation abilities and notes a scissors gait. Based on this data, which does the nurse suspect? a. Multiple sclerosis. b. muscular distrophy c. myasthenia gravis.
6. The nurse is performing a physical assessment of the client. Which pieces of information are examples of objective data? The nurse is performing a physical assessment of the client. Which pieces of information are examples of objective data? a. Apical pulse is 94 beats per minute. B.Blood pressure in right arm is 118/74. C.The client has a nonproductive cough. D. Respiratory rate is 18 breaths per minute. The client reports that his pain is severe and throbbing.
7 The nurse is interviewing a male client who states “I feel like I have a bag of worms in my scrotum.” Based on this data, which condition does the nurse suspect? varicocele epididymitis orchitis inguinal hernia.
8 The nurse is assessing a male client who has epididymitis. Which statement by the nurse would provide appropriate education regarding this condition? a. “Your sperm maturity may be affected.” b. "There will be a decrease in blood flow in your penis c. "There may be erectile difficulties" d. "You will have a decrease in testotesrone production.
9. The nurse notes asymmetry of the iliac crests and gluteal folds while inspecting the spine of a client. The client’s spine has a slight curvature to the right, but client denies complaints of pain. Based on this data, which term will the nurse use when documenting this finding in the medical record? Spinal list Lordosis Kyphosis Scoliosis.
10. The nurse is caring for a client experiencing vertigo and plans to perform the Romberg test during the assessment. Which instruction from the nurse regarding this test is the most appropriate? a. “Stand with your feet together, arms at sides, and eyes open.” b. "Touch your finger to your nose alternating hands" c."Walk on your toes then on your heels d. Walk across the room by placing one foot .
11 An adolescent client is seen for abdominal pain in the local clinic. The client states, “The pain is sort of all over my belly. I can’t really find one place that hurts more than another area.” Based on the nurse’s understanding about disorders of abdomen and associated symptomatology, which nursing diagnoses are appropriate for this client?
Standard Text: Select all that apply. a. Acute pain. b. Diarrhea. c. Altered nutrition, less than body requirements. d. Diarrhea Hypothermia.
12. The nurse is palpating the right upper quadrant of a client’s abdomen. Which organs may be assessed during this portion of the assessment?
Standard Text: Select all that apply. a.Liver b. Gallbladder c.Stomach d. spleen e. appendix.
13. During the assessment of a client’s renal system, the nurse is unable to palpate the kidneys. Which conclusion by the nurse is the most appropriate?
a.Normal b. A sign of polycystic kidney disease c. A sign of acute or chronic renal disease d. An indication of an inflammatory condition of the kidneys.
14. The nurse is measuring the urinary output for a client and notes 450 ml of urine. Which conclusion by the nurse is the most appropriate?
a.Normal amount b. Concentrated from what is normal c. Increased from normal d. Decreased from normal.
15. An older adult female comes into the clinic to be seen for urinary incontinence. Which conclusion by the nurse is the most appropriate? a. Often occurs as a secondary problem. b. Is common with aging c. Is related to medications d. Indicates decreased renal blood flow.
16. The nurse is interviewing the client and learns that the client has an open leg wound that has been draining a moderate amount of yellowish drainage over the last 3 days. Prior to assessing the client’s wound, which piece of personal protective equipment is most important for the nurse to wear based on the principles of standard precautions? a. Gloves. b.Mask c. Shoe covers d. Fluid-resistant gown.
17. The nurse is assessing a client to determine tremors associated with Parkinson disease. Which clinical manifestation does the nurse anticipate during the assessment? a. Rhythmic shaking b.Chorea c. Fasciculations d. Athetoid movements.
18. The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. Which is appropriate for the nurse to use when documenting this finding in the medical record?
a. Babinski response. b.Hyperreflexia c.Brudzinski sign d.Nuchal rigidity.
19. The nurse is reviewing the cranial nerves prior to a PRN shift on a neurological unit. Upon the review, the nurse notes that some of the nerves are exclusively sensory nerves. Which cranial nerves belong to this group?
Standard Text: Select all that apply. a. Olfactory nerve (cranial nerve I). B.Optic nerve (cranial nerve II). c. Facial Nerve (cranial nerve VII) Trochlear nerve ( cranial nerve IV).
20. The nurse is assessing a client whose chief complaint is an inability to move the fourth and fifth fingers. The nurse notes severe flexion in both of the affected fingers. Upon palpation, there are no complaints of pain from the client. Based on this data, which diagnosis does the nurse suspect? 1. Dupuytren contracture. 2. Arthritis 3. Crepitus 4. Bursitis.
21. The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the right upper portion of the back. The client states, “This has been happening more often after I eat rich, high-fat foods.” Which disorder does the nurse suspect based on these findings? 1. Cholecystitis. 2. Duodenal ulcer 3. Gastritis 4. Pancreatitis.
22. The nurse is performing a physical assessment of a male client. The nurse must assess the client’s sacrococcygeal area. Which position will allow the nurse to assess this area adequately?
1. On his left side with his knees drawn up. 2. Lithotomy 3. Orthopneic position 4. Semi-Fowler's position.
23. The nurse is assessing the function of the client’s cranial nerve XII (hypoglossal). Which activity will allow the nurse to assess this nerve during the client’s physical assessment?
1. “Can you stick out your tongue?” 2.Close your eyes and tell me when you feel me touch 3."Im going to lightly touch the back of your throat 4. "Im going to ask you taste somenthing.
24. A client comes to the emergency department (ED) complaining of a painful injury to the right knee received while playing basketball. Which examination techniques will the nurse include during the physical assessment of this client?
Standard Text: Select all that apply. 1. Inspection. 2. Palpation. 3. Bulge sign testing. 4. Ballottement. 5. Percussion. .
25. The nurse is assessing the client’s cardiovascular system during the physical assessment. Which location will the nurse use to palpate the point of maximal impulse/apical pulse?
1. A 2. B 3. C 4. D.
26. The nurse is examining the external genitalia of a female client and notes draining papules. Based on this data, which condition does the nurse suspect?
1.Syphilitic lesion. 2. genital warts 3. contact dermatitis 4.herpes infection.
27. The nurse is examining a male adolescent with suspected spermatic cord torsion. Which is the priority intervention for this client?
a.Prepare for surgery b.Elevate the scrotum c.Administer the anti-inflamatory medications d.Medicate for pain with narcotics.
28. The nurse is examining an adolescent female and notes no pubic hair on the pubis area. Based on this data, which action by the nurse is appropriate?
1.Document the findings as abnormal. 2. Examine the client for breast buds 3. Report the findings to the healthcare provider 4. Ask the client if she is menstruating.
29. The nurse is preparing to place the pulse oximeter sensor on the client. For which clients would the nurse use the earlobe to monitor pulse oximetry?
Standard Text: Select all that apply.
1. The client’s body mass index is 33 2. The client has been diagnosed with an evolving myocardial infarction. 3. The client is wearing dark nail polish. 4. The client is 82 years old.
5. The client has thickened nails.
30 The nurse is assessing a client that experienced a head injury using the Glasgow Coma Scale. Which findings are scored using the best motor response portion of the scale?
Standard Text: Select all that apply.
1. No response with eyes to commands. 2. Abnormal flexion to pain. 3. Pupil response sluggish. 4. Abnormal extension to pain. 5. Pupils fixed and dilated.
31. The nurse is mapping the client’s abdomen into four quadrants. Which landmarks would the nurse use to perform this assessment?
Standard Text: Select all that apply. 1. Umbilicus. 2. Midclavicular lines. 3. Xiphoid process. 4. Lower border of the right ribs.
5. Iliac crests. .
32. Since returning from surgery the client has not voided for 8 hours; therefore, the nurse determines it is necessary to assess the client for bladder distention. Which client position is appropriate for this assessment? 1. Supine with only a small pillow under their head. 2. Prone position 3. Lying in a left lateral position 4. Sitting in bed a 45-degree angle.
33 The nurse is providing education to a client who has been experiencing symptoms consistent with benign prostatic hyperplasia (BPH). The nurse presents a diagram the client to illustrate the location of the prostate. Which location will the nurse identify for the client during the teaching session? 1. A 2. B 3. C 4. D.
34. The nurse is performing a neurological assessment and needs to assess for vibration, as well as sharp and dull sensation. Which objects will the nurse use to complete this assessment? Standard Text: Select all that apply. 1. Tuning fork. 2. Paper clip. 3. Safety pin. 4. Cotton ball.
5. Tongue blade. .
35. The nurse works on a medical-surgical unit. Which clients will require a rapid assessment? Standard Text: Select all that apply.
1. The client had an open appendectomy 2 days ago and is preparing to be discharged today. 2. The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia. 3. The client has just been received from the Post Anesthesia Care Unit. 4. The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse. 5. The client begins to complain of difficulty breathing. The client’s oxygen saturation level has decreased from 93% on room air this morning to 87%. .
36. The nurse is preparing to assess the posterior spine of a client. Which is the landmark the nurse will use to determine symmetry? 1.A 2.B 3. C 4. D.
37. The client was recently admitted to the hospital with left lower quadrant pain. The client states, “It feels like my belly is cramping.” During the focused interview, the client admitted to experiencing a significant amount of occupational stress. Guarding is noted during the abdominal examination. The nurse reviews the medical record (see chart below) and concludes that the client has developed a diverticulitis. Which client statement supports this conclusion by the nurse? 1. “I get home so late at night, but I’ve got to stop lying down right after dinner. 2. “I drink a whole pot of coffee every day.” 3. “I drink 9–12 beers after I get home from work, every day.” 4. “We have been growing green beans in our garden and I think I ate too many the other day.” .
38. The nurse is assessing a client with a suspected femur fracture. Which assessment finding supports this diagnosis?
1. External rotation of the lower leg and foot. 2. Limited hip external rotation 3.Limited hip internal rotation 4. Internal rotation of the lower leg and foot.
40.The nurse is preparing to assess a female client’s external genitalia. Which structures will the nurse include in this assessment? 1. Vagina. 2. Cervix. 3. Clitoris. 4. Labia majora. 5. Labia minora. .
41. The nurse is providing care to a client whose chief complaint is pain in the right foot. During the physical assessment, the nurse notes a deviation of the great toe from the midline and crowding of the remaining toes. There is also enlargement and inflammation noted in the area. Based on this data, which condition does the nurse suspect?
1. Bunion. 2.Hammertoe 3.Gouty arthritis 4. Flat foot.
42. The nurse is speaking with the client during the focused interview. The client states, “My doctor said that my spleen was enlarged. Where is my spleen?” Which location will the nurse point to when answering this client’s question? 1.A 2.B 3.C 4.D.
43. The nurse is performing a routine assessment on a dark-skinned client who has been admitted to the hospital. The nurse is assessing the client’s oxygenation level and the presence of jaundice. Which statements indicate that the nurse is performing these specific assessments?
Standard Text: Select all that apply. 1. “I need to look at your eyes.” 2. “Please open your mouth for me.” 3. “Squeeze my fingers with your hands.” 4. “I am going to listen to your belly with my stethoscope.” 5. “I need to press on your fingernail.” .
44. The nurse is examining a female client and notes a greenish discharge with a foul odor. The client also exhibits guarding of the abdomen. Based on this data, which diagnosis does the nurse anticipate?
1. Gonorrhea. 2.Herpes infection 3. Bacterial vaginosis 4. Trichomoniasis.
45. The nurse is assessing the patellar reflex on a client and obtains no reflexive activity. The client is alert and oriented. Which action by the nurse is the most appropriate?
1. Retest the reflex after having the client use distraction during the exam. 2. Notify the healthcare provider inmediately 3.Document the findings as normal 4. Look at the medication records for central nervous.
46. The student nurse measures the client’s oxygen saturation level by using a pulse oximeter, and confers with the nurse preceptor after completion. Which statement by the student indicates the need for further education?
1. “A normal finding is that the client’s oxygen saturation level is above 70%. 2."This test is noninvasive and painless" 3. "I placed the sensor on the clients finger" 4. "The pulse oximeter can measure the oxigen saturation of the hemoglobin".
39. The nurse assesses the hospitalized client and prepares to document the findings using APIE in the medical record. Rank the following findings in the proper order of documentation.
Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. 1. The client states upon admission, “I don’t know what’s wrong with me, but I can’t see out of my left eye and I can’t stand up by myself.”
2. The client is unable to move from the bed to the chair without the assistance of two nurses. The client is unable to eat without assistance. 3. The healthcare provider writes an order for the nurse to administer heparin.
4. On the morning of the client’s discharge from the hospital, the client has been able to ambulate 50 feet with a walker. 5. 2, 1, 3, 4.
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