A 29 year old male client informs the nurse that he came to the clinic to see if,
“Maybe I have lung cancer or something,” and wants to get checked out since, “I
can’t seem to get rid of this body-wracking dry cough that has been hanging around
for the last six weeks.” Which computer documentation of this client’s concerns
should the nurse enter?
A. Presents with a hacking non-productive cough of 6 weeks duration.
B. Describe having a “body-wracking dry cough” of 6 weeks duration.
C. Expresses concern of “lung cancer” symptoms for the last 6 weeks.
D. Young adult male presents with fears that he has “lung cancer” – ANSWERCorrect answer is B, as assessment process includes chief complaint which is how
the patient describe why he is here in the hospital or clinic and can’t include
diagnosis.
A 75-year-old client with a recent history of a cerebrovascular accident (CVA)
presents with right hemiparesis. The nurse tests the deep tendon reflexes on the
right side and elicits a brisk 4+ response. Which interpretation of this finding is
accurate?
A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder. –
ANSWER- Correct answer is D, brisk 4+ response is correlated with hyperactive
response
The nurse examines a client’s abdomen. Which finding indicates an abnormal
response when palpating the spleen?
A. Pain notes when palpating McBurney’s point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant
D. Firm mass palpated at bottom of left rib cage. – ANSWER- Correct answer is D.
McBurney’s point is related to appendicitis and not spleen
A male client arrives at the clinic for follow-up health assessment after recent
antibiotic treatment for pneumonia without hospitalization. Which technique
should the nurse implement to assess for adventitious lung sounds?
A. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B.
Have the client lay flat while listening to the anterior surface of the chest.
C. Press the stethoscope’s diaphragm firmly on the skin over each lung field. D.
Shave all chest hair that may distort sounds heard through the diaphragm. –
ANSWER- Correct answer is C. The nurse should listen to all lungs fields during
assessment and move from side to side during auscultation
A client with streptococcus pharyngitis reports high fever, difficulty swallowing
and a muffled voice. Which complication should the nurse suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps. – ANSWER- Correct answer is C. Since infections are associated
with abscesses and pus
The nurse is obtaining a health history for a client prior to a scheduled
cholecystectomy. While interviewing the client, which assessment technique
should the nurse use when asking about the client’s use of illegal drugs and
alcohol?
A. Obtain a drug using screen to verify legitimacy of client’s stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.
D. Use the term illegal or illicit to describe street drugs – ANSWER- Correct
answer is C. When interviewing the patient, questions should be clear and specific
The nurse applies pressure over an area of the lower abdomen where the client
reports pain. The client denies pain upon palpation, but reports pain when the
pressure is released. What action should the nurse implement?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client’s bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness – ANSWER- Correct
answer is D. As this could be a sign of appendicitis
The nurse is assessing an ulcer on a client’s lower extremity, which is likely the
result of either venous or arterial insufficiency. Which assessment technique
should the nurse use to differentiate the pathophysiology causing the ulcer? A.
Measure the degree of join range of motion in the extremity.
B. Compare the skin turgor of the client’s upper and lower leg.
C. Observe the specific location and appearance of the ulceration.
D. Note any change in the color of the ulcer when the leg is moved – ANSWERCorrect answer is C. Location and appearance of the ulcer would give us the type
(venous vs arterial)
Venous: develop on the inner lower leg, shallow wounds that are large and
irregular edges that slope, red with granular tissue, discoloration with yellow
slough present, shiny skin warm or scaly
Arterial: occur most often on the foot, on the heels and around lateral malleolus,
round shaped, well-defined edges, yellow, brown or black in color, skin pale and
non granulating, deep but may also appear shallow in early stages, skin is thin,
smooth, taut, and dry. Loss of hair on the leg is also common
The nurse is conducting a physical assessment of a young adult. Which
information provides the best indication of the individual’s nutritional status? A.
Status of current appetite.
B. A 24-hour diet history.
C. History of a recent weight loss.
D. Condition of hair, nails, and skin – ANSWER- Correct answer is D. Hair, nail,
and skin are the most important reflection of nutritional status
The nurse is assessing a healthy adult male during an annual physical examination.
The nurse auscultates the client’s abdomen and hears gurgling sound every ten
seconds. What action should the nurse take in response to this finding?
A. Document this normal bowel sound activity in the record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of bleeding.
D. Report the hyperactivity to the healthcare provider. – ANSWER- Correct answer
is A. Normal Bowel sound consist of clicks and gurgles and 5-30 per minute. An
occasional borborygmus (loud prolonged gurgle) may be heard
In observing a client’s face, which assessment finding requires the most immediate
intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.
D. Face is flushed and diaphoretic. – ANSWER- Answer is C. Blue lips occur
when the skin on the lips takes on a bluish tint or color. This generally is due to
either a lack of oxygen in the blood or to extremely cold temperatures.
While obtaining a health history, a male client tells the nurse that he sometimes
experiences shortness of breath. The nurse determines that the client’s respirators
are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the
best nursing action?
A. Ask the client to perform light exercise and observe the respiratory effect. B.
Document “dyspnea on exertion” in the client’s medical record.
C. Ask the client to describe the episodes of dyspnea in more detail.
D. Explain to the client the possible causes of dyspnea or “shortness of breath.” –
ANSWER- Correct answer is C. Both respiratory rate and breath sounds are
normal. Further assessment is needed by asking the client to describe his SOB.
When assessing a male client’s respiratory status, which technique should the nurse
use to assess his anterior- posterior (AP) chest diameter?
A. Auscultation.
B. Percussion.
C. Palpation.
D. Observation. – ANSWER- Correct answer is D. Observation is the way to detect
barrel chest which is associated with COPD.
Which assessment finding supports the client statement, “My feet swell all the
time?”
A. 2+ pitting edema of ankles bilaterally.
B. Capillary refill both feet > 3 seconds.
C. Pedal pulses weak and thread.
D. Positive Homan’s sign bilaterally. – ANSWER- Correct answer is A. 2+ pitting
edema indicate swelling in the lower extremities
The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse
notes that the client has a reduced upward gaze, a decreased corneal reflex, a high
frequency hearing loss, and a reduced gag reflex. What action should the nurse
take next?
A. Review past history for any episodes of a cerebral cortex lesion.
B. Implement neuro vital signs every 2 hours to detect Cushing’s Triad.
C. Continue the assessment to the next pairs of cranial nerves.