Question 1

The nurse is performing a physical assessment on an older adult client.Which is the best reason for the nurse to ask this client about experiences with constipation?

Accepted Answer

Older adult clients commonly experience a natural decrease in the speed of intestinal peristalsis as part of the aging process. This slower peristalsis can lead to increased transit time of stool through the colon, resulting in more water being absorbed from the stool and, consequently, constipation.

Question 2

The nurse provides care for a client who is one day postoperative.The client reports nausea and is refusing to eat.The nurse assesses the client by auscultating the abdomen.Which cause will the nurse suspect if assessment reveals hypoactive bowel sounds?

Accepted Answer

Anesthesia can cause hypoactive bowel sounds postoperatively due to its effects on the gastrointestinal system, slowing down bowel motility.

Question 3

The nurse is performing an assessment of the client's eyes, and tells the client, "Focus on my pencil and follow it as I move it away from you and then back toward you." Which specific function is the nurse assessing?

Accepted Answer

The nurse is assessing the accommodation response, which is the ability of the eye to adjust its focus from distant to near objects. This is tested by having the client focus on an object as it moves closer to and further from the eyes.

Question 4

The nurse is leading orientation for a newly hired nurse.The newly hired nurse states, "I worry about getting all the information documented after an assessment.How do I remember everything?" Which advice by the orienting nurse will be most helpful?

Accepted Answer

Documenting in the same order as data is gathered, such as working from head to toe, helps create a systematic approach to both assessment and documentation, making it easier to remember and organize information.

Question 5

The nurse performs a physical assessment on a client who is just admitted for left lower-lobe pneumonia.The client describes experiencing an unproductive cough.Which assessment finding will support the nurse's suspicion of consolidation in the left lower lobe?

Accepted Answer

Absent breath sounds in the area of the left lower lobe would support the nurse's suspicion of consolidation due to pneumonia. Consolidation refers to the filling of the lung's airspaces with fluid, which can block the transmission of sound, leading to absent or significantly decreased breath sounds in the affected area.

Question 6

The charge nurse notes a client's blood pressure at 8:00 a.m.was 124/80 mm Hg.It is now 12:00 p.m., and the client's blood pressure is 152/94 mm Hg.Which suggestion about the plan of care will the charge nurse make to the newly hired nurse?

Accepted Answer

The client's blood pressure has increased significantly since the initial assessment. This suggests that the client may be experiencing a hypertensive crisis, which requires prompt medical attention. Therefore, the charge nurse should recommend that the client's blood pressure be rechecked in 1 to 2 hours to determine if it continues to rise.

Question 7

The nurse uses the five techniques for obtaining objective data when performing the physical assessment of a client.Which technique provides assessment information through the use of the nurse's hands?

Accepted Answer

Palpation involves the nurse using their hands to touch and feel various parts of the client's body to assess characteristics such as texture, temperature, moisture, motion, and the presence of lumps or masses.

Question 8

The nurse documents that the client is eupneic in regard to the client's respiratory status.Which interpretation of the nurse's documentation is correct?

Accepted Answer

Eupnea refers to normal, unlabored breathing, which includes a normal depth and rate of respiration, typically involving the use of abdominal muscles as part of the normal breathing process.

Question 9

During a staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell)to determine whether a client is exhibiting signs of illness or injury.Which description defines the assessment findings from these methods?

Accepted Answer

The assessment findings from using the senses of sight, touch, hearing, and smell are measurable because they involve objective data that can be observed and quantified by the nurse.

Question 10

The nurse plans additional time to build a relationship and establish rapport with a client admitted for surgery.Which is the most important reason for the nurse to promote this level of familiarity?

Accepted Answer

Establishing feelings of trust is crucial in a nurse-client relationship because it encourages open communication, ensures the client feels safe and supported, and enhances cooperation with care plans, including pre- and post-surgery instructions. Trust is foundational for effective healthcare delivery and patient satisfaction.

Question 11

The nurse is admitting a client diagnosed with congestive heart failure.Although the client is sitting in a semi-Fowler position, the nurse is unable to auscultate distinct heart tones.Which action should the nurse perform first?

Accepted Answer

Assisting the client to lean forward and toward the left side can help in better auscultation of heart tones, especially in patients with congestive heart failure, where fluid accumulation can make heart sounds muffled. This position change can enhance the clarity of the heart sounds.

Question 12

The nurse wakes the client during evening shift for a focused assessment.The client, trying to rest, tells the nurse, "I really need to sleep.Can you tell me why you need to wake me up so often?" Which response by the nurse explains the purpose of the assessment?

Accepted Answer

The correct answer is D because it provides a specific, understandable reason related to the client's care (monitoring for potential side effects or reactions to a new medication) for the frequent assessments, which justifies waking the client.

Question 13

The nurse is assessing the feet of an adult client who is hospitalized with uncontrolled diabetes mellitus.Assessment findings indicate an absence of cuts, cracks, or blisters.The client states, "I don't have as much feeling in my feet as I used to." Which condition does the nurse correctly identify for this client?

Accepted Answer

Paresthesia is the correct condition identified by the nurse, as it refers to abnormal sensations such as numbness or a lack of feeling, which the client describes experiencing in their feet. This is a common complication of uncontrolled diabetes mellitus due to diabetic neuropathy.

Question 14

The nurse is performing an initial physical assessment on a client.Which sequence does the nurse apply to correctly assess a client's abdomen?

Accepted Answer

The correct sequence for abdominal assessment is inspection, auscultation, and palpation. This order is important because palpation can alter bowel sounds, so auscultation should be performed before any palpation.

Question 15

After completing the initial head-to-toe shift assessment, the nurse determines that no changes are needed in the client's plan of care.Which evaluation process supports the nurse's decision?

Accepted Answer

Reviewing the effectiveness of previously initiated nursing interventions is a direct method for evaluating the current state of a client's health and determining if the existing plan of care remains appropriate. This process involves assessing whether the interventions have achieved the desired outcomes and if the client's condition has improved, remained stable, or deteriorated, thereby supporting the nurse's decision to maintain the current plan of care.

Question 16

The nurse is providing care for a female client who was admitted due to a stroke.The client becomes frustrated because of an inability to respond verbally to the nurse's questions.Which terminology should the nurse use to document this complication?

Accepted Answer

Aphasia is the correct term to describe a condition characterized by the inability to speak or understand language, which can occur as a complication of a stroke. Dysphasia is a related term but is less commonly used in clinical settings to describe language difficulties. Dysphagia refers to difficulty swallowing, and dyspnea refers to difficulty breathing, neither of which describes the inability to respond verbally.

Question 17

The nurse is performing a physical assessment at the change of shift on an older adult client.Assessment indicates a breathing rate of 30 breaths per minute, breath sounds are clear to auscultation in all five lobes, and the client denies dyspnea.Which finding does the nurse expect with assessment of the client's capillary refill?

Accepted Answer

Capillary refill time is normally less than 3 seconds. A capillary refill time of 5 seconds indicates delayed capillary refill, which can be a sign of poor peripheral perfusion.

Question 18

The initial assessment of a client admitted with a gastrointestinal inflammatory disease reveals that the client has hyperactive bowel sounds.The follow-up assessment indicates that the bowel sounds are still hyperactive, but are now audible without a stethoscope.Which documentation will the nurse make on the client's medical record?

Accepted Answer

Borborygmus refers to the rumbling or gurgling noise made by the movement of fluid and gas in the intestines that can be audible without a stethoscope, which matches the description given.

Question 19

The nurse performs a focused assessment.Which condition will provide the best information through the use of percussion?

Accepted Answer

Percussion is a technique used to assess the underlying structures by tapping on the body surface. Hyper-inflated lungs, as seen in conditions like emphysema, produce a hyper-resonant sound on percussion, providing valuable information about the lung condition.

Question 20

The nurse who is performing a physical assessment is preparing to auscultate breath sounds.Which position is most favorable position for performing the assessment of breath sounds?

Accepted Answer

The High Fowler position, where the patient is sitting up at a 90-degree angle, is most favorable for auscultating breath sounds because it allows for maximum lung expansion and makes it easier to hear the breath sounds throughout all lung fields.

Quiz 21: Physical Assessment