Deck 28: Putting It All Together

Question 1

The nurse is performing a physical assessment on a client in an outpatient clinic.The nurse is inspecting and palpating the client's face,skin folds,axillae,palms,and soles of the feet.The nurse determines the client is diaphoretic.Which of the following statements by the client are expected?
1)"Your elevator is out and I had to climb three flights of stairs."
2)"I've been running a fever for the last few days."
3)"I think I have hypothyroidism."
4)"I'm in a lot of pain today."
5)"I heard a rumor at work yesterday that layoffs were inevitable."

Answer 1

1,2,4,5

Question 2

The nurse is performing a physical assessment of the client.Identify the location of the right costovertebral angle on the following figure by drawing an arrow to the site.

Answer 2

Question 3

The nurse is assessing the client's neurologic system.The nurse tests the client's ability to perform stereognosis.Which of the following activities will accurately test this?
1)The nurse places a vibrating tuning fork over the client's ankle and asks the client to indicate when the vibration can no longer be felt.
2)The nurse asks the client to close her eyes and writes the number 7 in the client's palm with the base of the nurse's pen.The nurse asks the client to identify what was written.
3)The nurse asks the client to close her eyes and places a pen in the client's hand.The nurse asks the client to name the object in her hand.
4)The nurse asks the client to close her eyes and indicate where the nurse is touching the client.

Answer 3

3

Question 4

The nurse is assessing the client's cardiovascular system during the physical assessment.Identify the point of maximal impulse/apical impulse on the following figure by drawing an arrow to this site.

Question 5

During the physical assessment of the client,the nurse notes that the client is able to shrug her shoulders bilaterally.The function of which of the following cranial nerves is intact?
1)Cranial nerve I (olfactory)
2)Cranial nerve II (optic)
3)Cranial nerve VII (facial)
4)Cranial nerve XI (spinal accessory)

Question 6

The nurse prepares to palpate the client's preauricular lymph nodes.Identify the location of the preauricular lymph nodes on the following figure by drawing an arrow.

Question 7

The function of the client's cranial nerve XII (hypoglossal)is intact.The nurse is able to assess this nerve by asking the client to perform which of the following activities?
1)"Can you stick out your tongue?"
2)"I'm going to ask you to taste something and tell me what you think it is."
3)"Close your eyes and tell me when you feel me touch your face with this wisp of cotton."
4)"I'm going to lightly touch the back of your throat with this tongue depressor."

Question 8

The nurse holds the tuning fork by the handle and gently strikes the fork on the palm of his hand.Then,the nurse places the base of the fork on the client's mastoid process.The nurse requests that the client indicate when the sound can no longer be heard.Which of the following tests is the nurse performing?
1)Weber
2)Whisper
3)Rinne
4)Romberg

Question 9

The nurse is auscultating the client's lungs and is able to auscultate bronchovesicular sounds over the client's right lung.Identify the area where the nurse is able to auscultate these sounds by drawing an arrow to this area.

Question 10

The student nurse is preparing to assess the client while the more experienced nurse assists.Prior to the physical assessment,the client indicates that he has been experiencing severe left lower quadrant pain.Which of the following statements by the student nurse indicates that the student nurse requires further education prior to performing this part of the assessment?
1)"I'm going to start by percussing and palpating the client's left lower quadrant first."
2)"I will start the abdominal assessment by inspecting the client's abdomen."
3)"I'm going to auscultate the abdomen prior to percussing the abdomen."
4)"I need to ask the client about the characteristics of his pain."

Question 11

The nurse is assessing the client's cardiovascular system.The nurse is preparing to assess the client for the presence of a lift or heave.Which of the following directions should the nurse provide for the client?
1)"I am going to put you into a position where your feet are actually above your head."
2)"I need you to turn to your left side."
3)"Can you please turn onto your stomach?"
4)"I need you to sit up straight."
5)"I am going to elevate your head to a 30-degree angle while you lie on your back."

Question 12

The nurse is preparing to perform an interview to obtain information about the client.Which of the following are classified as secondary sources of information?
1)The client's wife
2)The client's medical record from his last hospital admission
3)The client
4)The client's daughter
5)The client's physical therapist

Question 13

The student nurse is preparing to insert the otoscope into the adult client's ear.Which of the following statements indicates that the student nurse requires further education?
1)"I'm going to use the largest speculum that will fit easily into the ear canal."
2)"I'm going to prepare to insert the otoscope by pulling the pinna down and back."
3)"The tympanic membrane should look gray and translucent."
4)"I will ask the client to perform the valsalva maneuver so that I can see how well the tympanic membrane moves."

Question 14

The student nurse percusses the client's abdomen.Which of the following statements by the student nurse indicate that tympany is present?
1)"The sound is low-pitched,loud,and hollow-sounding."
2)"It is a high-pitched,soft sound that doesn't last very long."
3)"The sound is very loud and has a low tone.The sound has a long duration."
4)"It sounds like a drum,loud and high-pitched."

Question 15

The nurse has palpated an abnormal mass within the client's scrotum.Which of the following assessment activities is appropriate for the nurse to perform next?
1)The nurse should percuss the client's scrotum.
2)The nurse should attempt to transilluminate behind the area in which the abnormal mass was palpated.
3)The nurse should inspect the inguinal area.
4)The nurse should gently squeeze the mass between the fingers.

Question 16

The client weighs 224 pounds.How many kilograms does the client weigh? Round to the nearest tenth.
_____ kilograms

Question 17

The client weighs 145 kilograms.The client is 1.75 meters.What is this client's body mass index (BMI)using the following formula: BMI = weight (kg)/height2 (meters)? Round to the nearest whole number.____

Question 18

The nurse is interviewing the client.Which of the following may lead to communication breakdown between the nurse and client?
1)The client is a Native American and the nurse is of Northern European descent.
2)During the interview,the nurse is trying to remember what the healthcare provider asked her to do earlier in the day.
3)The young nurse creates an informal atmosphere to discuss safe sexual practices with a teenaged client.
4)The young nurse uses a serious and respectful tone to discuss erectile dysfunction with an older client.
5)The nurse states,"So,you experience pain with micturation."

Question 19

The student nurse is performing a physical assessment for the client.The student nurse has identified a venous hum while auscultating the client's abdomen.Which of the following statements by the student nurse is most consistent with this type of vascular sound?
1)"The sound is a blowing,pulsing sound."
2)"The sound is soft and constant.The pitch of the sound is low."
3)"It is grating,rough sound."
4)"It is tinkling and has a high pitch.The sound is sort of gurgling and irregular."

Question 20

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 of the following pieces of personal protective equipment is most important for the nurse to wear based on the principles of standard precautions?
1)Fluid-resistant gown
2)Shoe covers
3)Mask
4)Gloves

Question 21

The nurse is performing an assessment of the female client's genitalia.The nurse has inserted a speculum and notices that the client has a frothy greenish-yellowish discharge present within the client's vagina.Based on the nurse's findings,the nurse believes that the client has developed which of the following conditions?
1)Trichomoniasis
2)Gonorrhea
3)Chlamydia
4)Candidiasis

Question 22

The nurse is performing a physical assessment of a male client.The nurse must assess the client's sacrococcygeal area.Which of the following positions will allow the nurse to assess this area adequately?
1)Orthopneic position
2)Semi-Fowler's position
3)Lithotomy
4)On his left side with his knees drawn up