NursGuru

    Exam Review

    1. When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?
      A)
      Use the stethoscope to listen over the carotid artery.
      B)
      Feel the volume of the dorsalis pedis and posterior tibialis pulses.
      C)
      Palpate the radial pulses in both arms for a deficit.
      D)
      Auscultate the apical pulse at the point of maximal impulse.
    2. While obtaining the health history of a client, the nurse learns the client's father was diagnosed with schizophrenia in his twenties, the same age the client is now. The client hesitates to discuss the topic and answer questions about the father. Which approach is best for the nurse to use to interview the client about mental health concerns?
      A)
      Ask questions in a vague, nonspecific format.
      B)
      Get the most difficult questions over with first.
      C)
      Begin with questions that are less sensitive in nature.
      D)
      Share personal values to put the client at ease.
    3. While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?
      A)
      A dull percussion tone outside the costal margins.
      B)
      Areas of tympany within the liver region.
      C)
      Tympany noted boarding the margins of the liver.
      D)
      A hollow sound over the lower abdomen.
    4. The college health clinic nurse is preparing a seminar on testicular self-examination (TSE). Which instruction should be included in the content for this seminar?
      A)
      Inspect the testicles using a mirror.
      B)
      Compare both testicles concurrently.
      C)
      Examine the testicles during bathing.
      D)
      Manipulate the testicles upon rising.

    Exam Review

    1. An older adult client comes to the healthcare provider's office for a routine follow up exam for high blood pressure, osteoarthritis, constipation, and chronic sinusitis. The client recently had a cataract removed from the left eye. Which is most important for the nurse to address when obtaining this client's health history?
      A)
      Obtain a medication history including prescription and non prescription drugs.
      B)
      Distinguish between symptoms caused by disease and those due to aging.
      C)
      Conduct an assessment of functional capacity and environmental hazards.
      D)
      Emphasize the need to place advance directives in the medical record.
    2. The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?
      A)
      Document this finding in the medical record.
      B)
      Schedule an appointment with a dermatologist.
      C)
      Ask if the client recently received any antibiotics.
      D)
      Ask the client about use of irritating chemical agents.
    3. The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?
      A)
      Diffuse abdominal pain with elevated neutrophil count.
      B)
      Anorexia progressing to nausea, vomiting, and fever.
      C)
      Periumbilical pain localizing to right lower quadrant.
      D)
      Sudden onset of severe anxiety, fear, and concern.
    4. When performing a skin and nail exam on an older adult female client, the nurse notes that she has longitudinal ridges on her fingernails. What does this finding indicate?
      A)
      Psoriasis.
      B)
      An expected variation.
      C)
      Fungal infection.
      D)
      Chronic obstructive pulmonary disease (COPD).

    Exam Review

    1. The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?
      A)
      Observe for any facial asymmetry.
      B)
      Assess for a positive Romberg sign.
      C)
      Check the pupillary response to light.
      D)
      Determine the response to stimuli.
    2. When assessing heart sounds of a client with rheumatic valvular heart disease, where should the nurse place the stethoscope to auscultate the tricuspid valve?
      A)
      Third left intercostal space.
      B)
      Left fifth intercostal space, midclavicular line.
      C)
      Left fourth intercostal space next to left sternal border.
      D)
      Second right intercostal space.
    3. In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at which location?
      A)
      1st intercostal space on the left
      B)
      Left side of the neck
      C)
      5th intercostal space on the right
      D)
      4th intercostal space on the right
    4. The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?
      A)
      Collect a urine sample and strain for granules or calculi.
      B)
      Ask the client if he took any pain medication at home.
      C)
      Observe for nonverbal signs to measure pain intensity.
      D)
      Use a standard pain assessment questionnaire and scale.

    Exam Review

    1. The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?
      A)
      Observe the client's urine for dark orange color.
      B)
      Examine client's sclera for icterus.
      C)
      Assess conjunctival sacs of lower lids for pallor.
      D)
      Review recent serum bilirubin levels.
    2. In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care? Reference Range:
      A)
      Imbalanced nutrition, less than body requirements.
      B)
      Excess fluid volume.
      C)
      Imbalanced nutrition, greater than body requirements.
      D)
      Deficient fluid volume.
    3. The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal?
      A)
      Drenching night sweats.
      B)
      Increase in sexual desire.
      C)
      Cessation of menstruation.
      D)
      Excessive vaginal moisture.
    4. Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?
      A)
      Right breath sounds louder than left.
      B)
      Slight crackling throughout lung fields.
      C)
      Faint whistling over both lung bases.
      D)
      Blowing, hollow sounds above sternum.

    Exam Review

    1. A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?
      A)
      Offer to teach a family member how to monitor the skin around the mole.
      B)
      Encourage the client to keep checking the mole with a magnifying mirror.
      C)
      Advise the client to see his healthcare provider for immediate evaluation.
      D)
      Ask the client if he often spends time outside in the sun without a shirt.
    2. The nurse is doing a health assessment of a client who smoked three packs of cigarettes every day for the last twenty years before quitting two years ago. How should the nurse document the client's pack-years? (Enter the numerical value only.)
    3. While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?
      A)
      Borborygmi sounds.
      B)
      Hypoactive bowel sounds.
      C)
      Hyperactive bowel sounds.
      D)
      Normal bowel sounds.
    4. The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?
      A)
      Petechiae.
      B)
      Hematoma.
      C)
      Ecchymosis.
      D)
      Vesicle.

    Exam Review

    1. During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?
      A)
      Proximal intertarsal joint swelling of big toe.
      B)
      Non-painful enlarged interphalangeal joints.
      C)
      Frozen, non-movable phalangeal joints.
      D)
      Distal interphalangeal joint nodules that deviate.
    2. While completing an admission assessment for a client with rectal bleeding, the nurse observes dried, dark red blood on the surface of a purple, shiny tissue mass that extrudes from the anal opening. When documenting in the client's electronic medical record (EMR), which finding should the nurse enter in the client's physical assessment?
      A)
      Serosanguineous and purulent exudate from anus.
      B)
      Anal mucosa prolapse and loose sphincter tone.
      C)
      Dried dark red blood on swollen external hemorrhoids.
      D)
      Tears of the anal mucosa with old blood around anus.
    3. The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?
      A)
      Absent deep tendon reflexes.
      B)
      Oxygen saturation of 85%.
      C)
      Capillary refill less than 3 seconds.
      D)
      3+ peripheral dependent edema.
    4. When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?
      A)
      Knee arthroplasty surgery.
      B)
      History of a fractured patella.
      C)
      Needle aspiration of the synovial space.
      D)
      Degenerative disease.