- A nurse has completed a cardiovascular assessment on a college athlete with a pulse of 50 beats per minute. What is the most appropriate interpretation of this assessment finding?
- This result is outside the normal range, therefore is an abnormal assessment finding.
- This assessment finding fits within the expected normal range for the adult pulse rate.
- The client’s pulse rate is a variation from the normal but is not a concern.
- The pulse is abnormal and the nurse must re-assess the pulse rate.
1) 3
Explanation:
- The normal range for the adult pulse rate is 60 to 100 beats per minute; however, for an athlete with a fit cardiovascular system it is not unusual to have a lower pulse rate. This is not an abnormal finding when put into context.
- A pulse rate of 50 beats per minute does not fit within the normal range for an adult of 60 to 100 beats per minute.
- The client’s pulse of 50 beats per minute is outside the normal range but is not a concern because this is not an unusual finding for an athlete with a well-developed cardiovascular system. Therefore, this result is not a concern when put into context.
- The pulse is outside the normal range but is not an unusual finding for a fit adult. It is unnecessary for the nurse to reassess the pulse rate.
Assessment
Application
Objective 4
Page 96
Difficulty = 3
2) A nurse is assessing for fremitus of the client’s chest wall. What is the correct method for performing this assessment?
1) Palmar surface of the fingers
2) Base of the fingers
3) Dorsal surface of the fingers
4) Finger pads
2) 2
Explanation:
- The palmar surface of the fingers is used to assess position, consistency, texture and size of structures, pain, and tenderness. Fremitus is best perceived with the base of the finger.
- Vibratory tremors felt through the chest wall are known as fremitus and are best perceived by the examiner when using the base of the fingers — the metacarpophalangeal joints.
- Temperature is best assessed using the dorsal surface of the fingers.
- The finger pads are utilized when performing light palpation.
Assessment
Application
Objective 1
Page 88
Difficulty = 2
3) A nurse is assessing a client who appears very anxious and is experiencing abdominal tenderness. What is the best approach to put the client at ease during this portion of the examination?
1) Palpate known painful areas first
2) Touch the abdomen before palpating it
3) Explain each movement after completion
4) Provide the client with an analgesic
3) 2
Explanation:
- Known painful areas are usually the last area to be palpated as pain and tenderness cause the client to tense.
- Touch informs the client that the examination of the abdomen is about to begin and may prevent a startled reaction.
- The client will be more relaxed if the nurse talks to them during the assessment, explaining each movement in advance rather than after the each movement.
- Providing an analgesic may decrease the abdominal discomfort but this intervention may not address the client’s anxiety about the examination.
Assessment
Analysis
Objective 3
Page 89
Difficulty =1
4) A nurse is using percussion to assess the liver. What sound would the nurse expect to hear?
1) Dullness
2) Hyperresonance
3) Tympany
4) Flatness
4) 1
Explanation:
- Dullness is a high-pitched tone that is soft and of short duration, usually heard over solid organs such as the liver.
- Hyperresonance is abnormally loud, heard when air is trapped in the lungs.
- Tympany is loud, high-pitched, drum-like and characteristic of an organ that is filled with air such as air-filled intestines.
- Flatness is a high-pitched tone, soft intensity, and short in duration that is typically heard over muscle or bone.
Assessment
Application
Objective 1
Page 91
Difficulty = 3
5) A nurse is examining a client in the Emergency Department. What finding would cue the nurse to complete a detailed neurological assessment?
1) Asymmetry of the client’s smile
2) Grimacing with movement
3) Talking in a loud voice
4) Edema to both legs
5) 1
Explanation:
- Asymmetry of facial expression is a cue to assess function of cranial nerves.
- Grimacing, guarding, or wincing when a client moves is a cue to examine for underlying pathology that may indicate joint or muscle problems.
- Talking in a loud voice is often a cue that the client is suffering from hearing loss.
- Edema to the legs is a cue that indicates circulatory or heart problems.
Assessment
Analysis
Objective 4
Page 95
Difficulty = 2
6) What is the correct technique to percuss the thorax of an infant?
1) Strike the nondominant hand with a closed fist of the dominant hand
2) Deliver two sharp blows to a hyperextended middle finger of the nondominant hand
3) Place the palmar surface of dominant hand against the body surface and apply gentle pressure.
4) Tap the area being examined directly with the fingertips of the dominant hand.
6) 4
Explanation:
- This is a description of blunt percussion used for assessing pain and tenderness in the gallbladder, liver, and kidneys.
- The technique used for indirect percussion is to deliver two sharp blows with the fingertips of the dominant hand to a hyperextended middle finger of the nondominant hand; however this is an inappropriate technique for percussing an infant thorax.
- This is a description of deep palpation and is not a percussion technique.
- This is a description of direct percussion, the correct technique used to percuss an infant thorax.
Assessment
Application
Objective 1
Page 89
Difficulty = 3
7) A nurse is auscultating breath sounds on an adult male client and hears a crackling sound over most of the chest. What should the nurse do next?
1) Document this as an abnormal finding.
2) Wet the chest hair and re-auscultate.
3) Ask the client to cough, then auscultate again.
4) Turn the diaphragm of the stethoscope to the bell.
7) 2
Explanation:
- This may or may not be an abnormal finding and should be ruled out first before documenting.
- Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid this problem, the hair should be wet before auscultating the area.
- Coughing may clear bronchial secretions, but this is not the cause of the crackling sound.
- Friction from the hair will cause an abnormal crackling sound regardless of whether the bell or diaphragm are used therefore switching them won’t make a difference.
Implementation
Analysis
Objective 4
Page 94
Difficulty =1
8) A nurse is performing an abdominal assessment and has just completed inspection. What is the next step in this assessment?
1) Percussion
2) Palpation
3) Documentation
4) Auscultation
8) 4
Explanation:
- If percussion was used after inspection there is the potential to alter the natural sounds of the abdomen, therefore auscultation is the next technique to use in order to listen to unaltered sounds.
- If palpation was used after inspection there is the potential to alter the natural sounds of the abdomen, therefore auscultation is the next technique to use in order to listen to unaltered sounds.
- It is premature to document because the abdominal assessment is incomplete. The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation.
- Inspection should be performed first followed by auscultation to avoid altering the natural sounds of the abdomen that could occur if either percussion or palpation techniques were used next.
Assessment
Application
Objective 1
Page 87
Difficulty=1
9) A nurse is preparing to examine several clients in the clinic setting. Which client would need the greatest degree of special consideration during a physical examination?
1) Fifty-nine-year-old with influenza
2) Nineteen-year-old who complains of fatigue
3) Three-year-old child in for a well check-up
4) Seventy-eight-year-old with COPD
9) 4
Explanation:
- Influenza is an acute condition but does not put the client in the same risk category as the older client with a chronic disease.
- Fatigue in teenagers may indicate anemia but it may be caused by lack of sleep.
- Assessment approaches and techniques may vary for children, but a healthy three-year-old is not considered at the same risk potential as a client with a chronic respiratory illness.
- Clients who are frail, weak, debilitated, or suffering from a chronic illness are at greatest risk during physical examination and the exam may be exhausting for them, therefore the nurse will need to adapt the examination accordingly.
Assessment
Analysis
Objective 3
Page 96
Difficulty =2
10) What is the correct technique for moderate palpation of the abdomen?
1) Downward one to two cm
2) Side to side one-half to one cm
3) Upward three to four cm
4) Side to side two to three cm
10) 1
Explanation:
- Moderate palpation is used to assess underlying structures. The correct technique is to press downward approximately one to two cm while rotating the fingers in a circular motion.
- A side-to-side motion is not a palpation technique.
- Deep palpation is to a depth of two to four cm; however the technique calls for a downward motion and not an upward motion.
- A side-to-side motion is not a palpation technique.
Assessment
Application
Objective 1
Page 89
Difficulty = 3
11) A nurse is assessing a client when he refuses to allow the nurse to continue the examination. What should the nurse do next?
1) Provide a translator to explain the examination process to the client.
2) Document which procedures took place and which were refused.
3) Ask a nurse of the same gender as the client to stay in the room as a witness.
4) Suggest a family member tell the client to allow the examination to proceed.
11) 2
Explanation:
- Providing a translator may help the client understand the procedure, but the client should be allowed to object to any and all physical examination techniques. There is no indication in this scenario that the client required translation services.
- Although explaining the reason for a certain procedure may help the client understand its benefit, a client should never be forced, influenced or coerced to agree to any and in all cases. Documentation of which procedures took place and which were refused is extremely important.
- Allowing a family member to be present during the exam may be helpful, but a family member should not be used to force, influence, or coerce the client. The client’s wishes must be respected.
- Asking another nurse to stay in the room as a witness is not respecting the client’s wish to stop the examination. The nurse should document what part of the examination was completed and what was refused.
Assessment
Application
Objective 3
Page 96
Difficulty = 1
12) What special equipment is required to accurately measure the degree of joint flexion?
- Transilluminator
- Wood’s lamp
- Sphygmomanometer
- Goniometer
12) 4
Explanation:
- A transilluminator is used to detect blood, fluid, or masses in body cavities.
- Wood’s lamp is used to detect fungal infections of the skin.
- A sphygmomanometer is used to measure blood pressure.
- A goniometer measures the degree of joint flexion and extension.
Assessment
Application
Objective 2
Page 93 (Table 6.1)
Difficulty = 1
13) A nurse is using a Doppler ultrasonic stethoscope to assess a pulse and does not hear anything. What is the most appropriate nursing action?
1) Check the pressure applied to the probe
2) Add more gel to the end of the probe
3) Immediately inform a physician
4) Send the equipment for repair
13) 1
Explanation:
- Heavy pressure to the probe should be avoided because it may impede blood flow — the probe should be placed gently against the client’s skin, over the artery to be auscultated.
- A small amount of gel is applied to the end of the Doppler probe to eliminate interference but this step should have been completed prior to beginning the pulse assessment.
- Informing a physician may be premature until it is determined that the Doppler probe is being used correctly.
- Sending the equipment for repair is premature at this time.
Implementation
Analysis
Objective 4
Page 94
Difficulty = 2
14) A nurse is using an ophthalmoscope with a red-free filter to assess the optic disc in a client. What colour indicates hemorrhaging of the optic disc?
1) Green
2) Black
3) Red
4) Yellow
14) 2
Explanation:
- The red-free filter shines a green beam but it is the black colour that indicates an optic disc hemorrhage.
- The red-free filter shines a green beam used to examine the optic disc for pallor or hemorrhage, which, when present, appears black through this filter.
- A red-free filter means that red will not be visualized.
- Yellow is not a colour visualized with an opthalmoscope.
Assessment
Application
Objective 2
Page 94
Difficulty = 2
15) A nurse is preparing to assess a client’s abdomen. What is the correct order to assess this body area?
1) Inspection, Palpation, Percussion, Auscultation
2) Inspection, Palpation, Auscultation, Percussion
3) Inspection, Palpation, Percussion, Auscultation
4) Inspection, Auscultation, Percussion, Palpation
15) 4
Explanation:
- Inspection, palpation, percussion, and auscultation is the usual order for assessment except when assessing the abdomen, the order is then inspection, auscultation, percussion, and palpation.
- Wrong order for an abdominal assessment. The order is inspection, auscultation, percussion, and palpation.
- Auscultation follows inspection in an abdominal assessment because the bowel sounds may be altered by percussing and palpating the abdomen prior to doing the auscultation.
- The typical pattern for assessment varies when assessing the abdomen. The order when assessing the abdomen is inspection, auscultation, percussion, and palpation.
Planning
Comprehension
Objective 1
Page 87
Difficulty = 1
16) What initial nursing action can help alleviate a client’s anxiety about a physical examination?
- Provide the client with teaching during the examination
- Ask another nurse to be present during the physical assessment.
- Allow the client to void prior to starting the examination.
- Perform assessments that a client knows such as height and weight
16) 4
Explanation:
- Providing the client with teaching during the exam is a useful strategy to alleviate anxiety, enhance understanding, and to give the client a sense of partnership in his or her healthcare but this is not an initial nursing action used to alleviate client anxiety about the examination. A highly anxious client may not absorb the teaching information.
- This may be a useful strategy to help alleviate client anxiety but the nurse must first ask the client if this approach would make him or her more comfortable. In some situations this might increase client anxiety.
- A client will feel physically more comfortable with an empty bladder but this strategy does not address the client’s emotional needs concerning the anxiety about the actual examination.
- A nurse can alleviate the client’s anxiety by approaching the examination gradually by performing simple measurements, such as height, weight, temperature, and pulse which most clients find familiar and nonthreatening.
Assessment
Application
Objective 3
Page 96 and 97
Difficulty = 2
17) What is the best approach to accurately assess for vocal fremitus?
1) The ulnar surface of the fingers of the dominant hand.
2) The dorsal surface of the fingers on the nondominant hand.
3) The palmar aspect of the fingers of the dominant hand.
4) The fingertips of either hand.
17) 1
Explanation:
- The ulnar surface of the hand including the finger is most sensitive to vibrations such as fremitus and the dominant hand is always more sensitive than the nondominant hand.
- The dorsal surface of the fingers is best used to assess temperature rather than fremitus (e.g. vibrations)
- The palmar aspect of the fingers is best used to determine position, consistency, texture, size of structures, pain, and tenderness.
- The finger pads are used in percussion.
Planning
Application
Objective 1
Page 88
Difficulty = 3
18) A client has an inflamed area on the left forearm. What assessment techniques should the nurse use to assess this area?
1) Percussion
2) Light palpation
3) Moderate palpation
4) Deep palpation
18) 2
Explanation:
- Percussion would not be an appropriate technique to use to assess an inflamed area. Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid.
- Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin.
- Moderate palpation is used to assess most of the other structures of the body.
- Deep palpation is used to assess an organ that lies deep within a body cavity.
Planning
Application
Objective 1
Page 88
Difficulty = 1
19) A client has a visible pulsation in the middle of his abdomen. What assessment technique should the nurse use to assess this pulsation?
1) Direct percussion
2) Light palpation
3) Moderate palpation
4) Deep palpation
19) 3
Explanation:
- Percussion is not an appropriate technique to use in this situation. Direct percussion is used to assess a thorax of an infant or the sinuses of an adult.
- Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin.
- With moderate palpation, the nurse can determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present.
- Deep palpation is used to assess an organ that lies deep within a body cavity. Also in this situation deep palpation could result in the rupture of a pulsating mass such as an abdominal aneurysm.
Implementation
Application
Objective 4
Page 89
Difficulty = 2
20) A nurse has documented that a client’s lung sounds are hyperresonant. What is the correct interpretation of this assessment finding?
- Air is trapped in the lungs and has hollow quality.
- High pitched sound that is drum like in quality.
- Flat, soft tone that indicates the lung is solidified.
- Dull, high-pitched tone that is of short duration
20) 1
Explanation:
- Hyperresonance is an abnormally loud, low tone that is heard when air is trapped in the lungs.
- A high pitched sound that is drum like is known as tympany and is heard over air-filled intestines.
- Flatness is a high-pitched tone that is soft and occurs over solid tissue such as muscle or bone.
- Dullness that is high-pitched and of short duration is normal percussion sound heard over the liver.
Assessment
Application
Objective 4
Page 91
Difficulty = 3
21) A nurse is preparing to percuss the lower lobes of a client’s lungs. What is the appropriate percussion technique to use?
1) Direct percussion
2) Blunt percussion
3) Indirect percussion
4) Any of the percussion techniques
21) 3
Explanation:
- Direct percussion is used to examine the thorax of an infant and to assess the sinuses of an adult.
- Blunt is used for assessing pain and tenderness in the gallbladder, liver, and kidneys.
- Indirect percussion is the technique most commonly used because it produces sounds that are clearer and more easily interpreted when assessing lung fields.
- The appropriate percussion technique must be used to ensure accurate assessment results and the only appropriate technique to use to percuss the lungs is the indirect percussion technique.
Planning
Application
Objective 4
Page 89 and 90
Difficulty = 2
22) While percussing a client’s lung area the nurse notes a flat tone. What does this flat tone indicate?
1) The nurse is percussing over a bone.
2) A normal finding.
3) The lungs are solidified.
4) Air is trapped in the lungs.
22) 1
Explanation:
- A flat tone or flatness is characteristic of percussing over solid tissue like muscle or bone.
- Since the nurse is intending to percuss the lungs this is not a normal finding. Resonance is a normal percussion sound over the lungs.
- If the lungs were solidified the nurse is more likely to hear dullness similar to what is heard over a solid organ.
- Hyperresonance is the characteristic sound when air is trapped in the lungs.
Evaluation
Analysis
Objective 4
Page 91
Difficulty = 3
23) While auscultating a client’s lungs, the nurse identifies more than one sound. What is the most appropriate nursing action?
1) Use a different stethoscope.
2) Ask another nurse to listen to the lung sounds.
3) Hold the stethoscope tubing while listening to the lung sounds.
4) Close the eyes and focus on one sound at a time.
23) 4
Explanation:
- It is premature to use another stethoscope. It is not uncommon for a nurse to hear more than one sound at a time; therefore it is important for the nurse to focus on each sound by closing her eyes and concentrating.
- This might be an appropriate next step after the nurse tries to focus on the sounds by closing her eyes and concentrating. Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard.
- Touching the stethoscope tubing can cause additional sounds and should be avoided
- Closing the eyes and concentrating on each sound might help the nurse focus on the sound.
Assessment
Application
Objective 4
Page 91
Difficulty = 2
24) What nursing action would indicate that the nurse is following routine practices during a physical examination?
- Observe for signs of dizziness when the client takes deep breaths.
- Explain procedures in advance to alleviate client anxiety.
- Perform hand hygiene in the presence of the client.
- Drape the client to preserve privacy and to provide warmth.
24) 3
Explanation:
- This is an example of providing a safe environment for the client, although this is an important element of a physical examination this is not a routine practice. Routine practices refer to maintaining principles of asepsis and body fluid precautions.
- This is an example of providing a comfortable environment for the client, although this is an important element of a physical examination this is not a routine practice. Routine practices refer to maintaining principles of asepsis and body fluid precautions.
- The nurse is require to follow routine practices such as hand washing, use of protective barriers, and the disposal of sharps throughout a physical examination.
- This is an example of providing a safe and comfortable environment for the client and not routine practices.
Assessment
Application
Objective 5
Page 97
Difficulty = 3
25) What approach will the nurse use to survey the client during the inspection phase of a physical assessment?
- Start inspection with the painful area first
- Compare the right and left sides of the body
- Proceed from a specific focus to a general overview
- Instruments are only used during the other phases of assessment
25) 2
Explanation:
- The nurse needs to be aware of the client’s concerns while doing an assessment but generally an inspection begins with a survey of the client’s appearance and a comparison of the right and left sides of the client’s body. The nurse should proceed from a general overview then to specific detail.
- This is the correct approach. Compare right and left sides of the body for symmetry and proceed from a general overview to specific detail.
- This approach is backwards. The nurse should proceed from a general overview to specific detail comparing the right and left side of the client’s body for symmetry.
- Most of the inspection will be done without instruments; however, there are areas of the body (e.g. internal structures of the ear) that require instruments in order to visualize this region of the body. The principle of surveying the general and then the specific still applies therefore instruments will be used after the general survey has been completed.
Assessment
Application
Objective 1
Page 88
Difficulty = 1
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.
26) What part of the stethoscope is used to auscultate heart murmurs? Draw an arrow to identify this part on the stethoscope.
26)
Explanation
The deep, hollow end piece, the bell, detects low-frequency sounds such as heart murmurs and should be used when auscultating this type of heart sound. The diaphragm is used to auscultate normal heart sounds.
Assessment
Application
Objective 2
Page 91
Difficulty = 2
Chapter 7
MULTIPLE CHOICE. Choose the one alternative that best answers the question.
1) A nurse is assessing Ami, 2 years old, when the mother tells the nurse that Ami has had a fever for the past two days. When the nurse asks the mother what the temperature has been, the mother replies that she hasn’t actually taken it but Ami’s skin has felt very warm. What would be the most appropriate response for the nurse?
1) “When our skin feels warm, it means our blood vessels are constricted.”
2) “The only reliable indicator of body temperature is by feeling the forehead.”
3) “Our skin temperature changes when our surroundings change temperature.”
4) “The temperature of the skin is not related to what is happening inside our bodies.”
1) 3
Explanation:
- Vasoconstriction is a way for the body to prevent heat loss. Vasodilation occurs with increased body temperature to increase loss of heat.
- To obtain accurate temperature, the core temperature or the temperature of the deep tissues of the body needs to be assessed.
- The surface temperature of the body is constantly changing in response to environmental influences and as a result is not a reliable indicator of actual health status.
- As body temperature increases the skin will feel warmer.
Assessment
Application
Objective – 5
Page – 102
Difficulty – 2
2) Zavier, 8 months old, is having a well baby examination. During the examination, Zavier has a liquid stool. The mother becomes very angry and asks the nurse to change the diaper because she just can’t “deal with the odour”. What observation should the nurse make?
1) The child may have an illness causing diarrhea.
2) It may be a reflection of the mother-child relationship.
3) The mother is behaving inappropriately.
4) The child may have an illness that is increasing the odour of stool.
2) 3
Explanation:
- Although the child may have an illness, the mother’s response to the stool is inappropriate.
- There is insufficient information to draw this conclusion. There is no indication that Zavier is not responding to his mother.
- Observation of the interaction between Zavier and his mother can provide information suggestive of child abuse. The mother’s demonstration of disgust with any aspect of child’s behaviour or such things as odour or stool can be clues that there may be a problem with the relationship and should be evaluated further.
- This may be true, but the mother’s response is inappropriate and needs to be investigated further.
Assessment
Analysis
Objective – 5
Page – 100
Difficulty – 3
3) A nursing assistant brings the nurse the following vital signs for a 90-year-old client: Temperature 36.3 o C (oral), BP 165/70 mmHg, Pulse 84 and Respirations 24. After examining the vital signs, what action should the nurse take?
1) Continue to monitor the client.
2) Tell the nursing assistant to recheck the temperature.
3) Obtain an order for an antihypertensive.
4) Obtain an order for oxygen therapy.
3) 1
Explanation:
- Normal variations in vital signs occur with aging. Body temperature may be decreased due to a decrease in the thermoregulatory control and loss of subcutaneous fat. The pulse rate remains within the normal range of 60 to 100 BPM. A decrease in vital capacity and inspiratory reserve volume may result in an increased respiratory rate. Because systemic arteries lose elasticity with aging, the heart has greater resistance to pump against which can result in an increased systolic blood pressure.
- The vital signs are within normal limits for an elderly client and do need to be repeated.
- The nurse would need to do an assessment and take history before obtaining an order for an antihypertensive.
- There is no indication that oxygen is required.
Assessment
Application
Objective – 3
Page – 103, 104, 105, 106
Difficulty – 3
4) A nurse is obtaining the height and weight of an 84-year-old client. The client asks why the height is 2 cm less than last year. What would be the best response by the nurse?
1) “Your bones are weaker and are shrinking.”
2) “I am sure you are mistaken and just don’t remember from last year.”
3) “Your height decreases with age due to bone changes.”
4) “Stand up straighter this time and we will measure again.”
4) 3
Explanation:
- Bones may become more brittle but they do not shrink.
- This is an inappropriate response by the nurse.
- Height of older adults may decrease as a result of thinning of the intervertebral discs. There can also be a flexion of the hips and knees, which affects the ability to stand erect.
- Older adults may decrease in height due to a thinning of the intervertebral disc.
Assessment
Analysis
Objective – 5
Page – 102
Difficulty – 2
5) A nurse is obtaining the initial vital signs on a client in the emergency room following a seizure. What method should the nurse use for obtaining the client’s temperature?
1) Axillary
2) Oral
3) Rectal
4) Tympanic
5) 3
Explanation:
- Although axillary is the safest, it is also the least accurate.
- If the client starts to seizure while taking an oral temperature the thermometer could cause injury.
- A rectal temperature should be taken if the client is comatose, confused, having seizures, or unable to close the mouth.
- A tympanic require the client’s cooperation in order to maintain safety, which is not possible during seizure activity.
Assessment
Application
Objective – 3
Page – 103
Difficulty – 1
6) Mr. Dwyer, 29 years old, is admitted with pneumonia. His vital signs are: Temperature 38.5 0 C (oral), BP 100/70 mm Hg, Pulse Rate 110/min and Respirations 22. The client’s oxygen saturation level is 96%. Which order should the nurse clarify with the physician?
1) Administer PRN antipyretic
2) Administer intravenous fluids
3) Start oxygen therapy
4) Send for chest x-ray
6) 3
Explanation:
- The vital signs are expected findings with the Mr. Dwyer’s diagnosis and an elevated temperature.
- The decreased BP is secondary to the elevated body temperature, which results in peripheral vasodilation in an attempt to increase heat loss. The decrease in blood pressure causes an increased pulse rate. Intravenous fluids would be applicable for these reasons.
- As Mr. Dwyer’s oxygen saturation level is within normal limits oxygen is not indicated at this time.
- The slight increase in respiratory rate is secondary to the pneumonia as well as the increase in temperature. A chest film would be indicated to determine the extent of pulmonary involvement.
Planning
Analysis
Objective – 5
Page – 105, 106
Difficulty – 3
7) A nurse is caring for a client with an irregular heart rhythm. How long should the nurse count beats for this client when taking a pulse rate?
1) Two minutes
2) A full minute
3) 30 seconds and multiply by 2
4) 15 seconds and multiply by 4
7) 2
Explanation:
- One minute is required for taking a pulse on a client with an irregular heart rate.
- With any irregular pulse, the rate needs to be counted for one full minute.
- If the pulse is regular, then the nurse may count the beats for 30 seconds and multiply by two.
- A client with an irregular heart rate has the pulse taken for 1 minute.
Assessment
Application
Objective – 4
Page – 105
Difficulty – 1
8) A nurse is admitting a client with diabetic ketoacidosis. The LPN asks the RN if the pulse oximeter needs to be placed on the client. What is the nurse’s best response to the LPN?
1) “Please place the pulse oximeter on the client.”
2) “I will let you know after I complete my assessment.”
3) “Thanks, for that is something I have to do for the client.”
4) “We don’t have an order to do that.”
8) 2
Explanation:
- The client may not require a pulse oximeter as it does not provide information about acid-base balance or blood glucose levels. It only reflects the percentage of oxygen saturation of hemoglobin.
- The nurse should complete the assessment to determine any respiratory abnormalities before using the pulse oximeter.
- There is no indication that the client requires a pulse oximeter. The nurse needs to assess the client first.
- This would not require a physician’s order, but could be delegated to the LPN.
Planning
Application
Objective – 4
Page – 105, 106
Difficulty – 1
9) What is the purpose of a general survey?
1) Allows for vital signs prior to starting exam.
2) Provides an opportunity for the patient to relax before the exam.
3) Yields information to guide the physical assessment.
4) Provides the information necessary for the diagnosis.
9) 3
Explanation:
- Vital signs are not part of the general survey.
- The general survey is part of the examination.
- The general survey allows the nurse to observe the client and gain clues for guiding the remainder of the assessment.
- It does not provide information for a nursing diagnosis, but information to guide the physical assessment.
Assessment
Comprehension
Objective – 1
Page – 99
Difficulty – 1
10) Mrs. Sandler, 34 years old, is being admitted. She is changing her position frequently, wringing her hands, and laughing at inappropriate times. What should the nurse include in the assessment based on this information?
1) Anxiety assessment
2) Mental status testing
3) Attention deficit testing
4) Nutrition assessment
10) 1
Explanation:
- Body language and verbal responses can be key indicators of anxiety. If the patient exhibits anxiety during the interview it may be a reflection of anxiety related to the situation or a need for further assessment. One means used to further evaluate the anxiety is the use of an anxiety scale.
- There is no indication the client is not oriented to time, place and person.
- There is not indication for this. The behaviours are consistent with someone who is anxious.
- The behaviours exhibited by the Mrs. Sandler indicate anxiety.
Assessment
Application
Objective – 1
Page – 100
Difficulty – 1
11) Mrs. Kellogg, 69 years old, is admitted with a fractured hip. She points to the painful hip and describes it as a constant throbbing. What would the nurse include in a pain assessment?
1) Precipitating and relieving factors, impact on ADLs, and coping strategies
2) Location, quality, and impact on ADLs
3) Quality, pattern, and precipitating factors
4) Precipitating and relieving factors, location, and impact on ADLs
11) 1
Explanation:
- Pain assessment should include data about the location, intensity, quality, pattern, precipitating factors, actions undertaken for relief of pain and effects, impact on ADLs, coping strategies and emotional responses. Kellogg’s description in the question already includes the quality, location, and pattern.
- Kellogg has already indicated the location and quality of the pain.
- Kellogg has already indicated the quality and the pattern of the pain.
- Kellogg has indicated the location of the pain.
Assessment
Analysis
Objective – 3
Page – 108, 109
Difficulty – 2
12) During an interview with a client, the nurse notes confusion as to day and time. What aspect of the mental status examination should the nurse evaluate further?
1) Affect and mood
2) Orientation
3) Willingness to cooperate
4) Level of anxiety
12) 2
Explanation:
- There is no indication the affect or mode is a concern.
- Client’s ability to state their name, location, and the date and time of day assesses for their orientation to person, place, and time.
- There is no indication that the client is uncooperative.
- There is no evidence that the client is anxious.
Assessment
Application
Objective – 2
Page – 100
Difficulty – 1
13) Mr. Sandhu, 85 years old, is admitted with arteriosclerosis. His blood pressure at 06h00 is 172/98 mm Hg. What factor may contribute to Mr. Sandhu’s blood pressure?
1) Blood pressure is increased in obese people
2) Arteriosclerosis increases blood vessel elasticity
3) Blood pressure is highest in the morning
4) Blood vessels lose their elasticity with age
13) 4
Explanation:
- There is no indication that Mr. Sandu is obese.
- Arteriosclerosis results in hardened and rigid arteries, which are less compliant. This requires greater ventricular force and leads to increased blood pressure.
- Blood pressure is usually lower in the morning.
- Elasticity of blood vessels decreases with age and also leads to increased blood pressure.
Assessment
Comprehension
Objective – 4
Page – 106
Difficulty – 2
14) What is the meaning of the numbers in a blood pressure reading?
1) Bottom number is the pressure between ventricular contractions
2) Bottom number is a reflection of cardiac output
3) Top number is the result of the heart rate
4) Top number reflects the pressure of blood generated when the right ventricle contracts
14) 1
Explanation:
- The bottom number is the diastolic pressure. This is a reflection of the heart at rest.
- The diastolic pressure, bottom number, is not a direct reflection of cardiac output.
- The diastolic pressure, bottom, number, is a result of the heart at rest.
- Systolic pressure (top number) is the pressure of blood at the height of a wave produced by left ventricular contraction.
Assessment
Comprehension
Objective – 3
Page – 106
Difficulty – 1
15) A nurse needs to take a blood pressure on a thin client, and the only cuff available is a standard sized cuff. The nurse would correctly anticipate what readings?
1) Accurate reading
2) Falsely elevated reading
3) Reading will depend of the overall health of the client
4) False low reading
15) 4
Explanation:
- The bladder of the blood pressure cuff must be appropriate for both the length and width of the client’s arm. The width of the bladder should be 40% of the circumference of the limb. The length should be 80% of the circumference of the limb.
- If the bladder is too narrow, the blood pressure reading will be falsely high.
- The reading will be impacted by the size of the blood pressure cuff.
- If the bladder is too wide, the blood pressure will be too low
Assessment
Application
Objective – 4
Page – 107
Difficulty – 1
16) Mrs. Choi, 48 years old, had a left-sided mastectomy two days ago. The nurse has delegated vital signs on this client to an unregulated health care provider. What specific instructions would the nurse provide in delegating this task?
1) Take the blood pressure on the right arm
2) Use the electronic blood pressure machine
3) Take the blood pressure on the left arm
4) Take the blood pressure on both arms for a baseline
16) 1
Explanation:
- Blood pressures should not be taken on the same side as a mastectomy. It should also not be taken on an arm with a shunt, trauma, or disease. In these situations, the opposite arm should be utilized.
- Even with the use of a electronic blood pressure machine the nurse must indicate that the left arm is not to be used.
- Blood pressure must not be taken on an arm with a shunt, trauma, or disease.
- Blood pressure must not be taken on the left arm.
Planning
Application
Objective – 5
Page – 107
Difficulty – 1
17) Mandy, 6 weeks old, needs her vital signs taken as part of a well baby assessment. What represents appropriate routes and sequence for obtaining vital signs on Mandy?
1) Rectal temperature, respirations, pulse rate
2) Respirations, pulse rate, blood pressure, rectal temperature
3) Respirations, apical pulse rate, axillary temperature
4) Oral temperature, respirations, pulse rate, blood pressure
17) 3
Explanation:
- Although a rectal temperature is the most accurate, an axillary should be done in infants to avoid the risk of rectal perforation.
- Blood pressure is not a routine vital sign taken on a healthy infant. The rectal route would not be used on an infant due to the risk of rectal injury.
- Respirations and apex should be taken first as Mandy may cry when her temperature is taken.
- An oral temperature is an inappropriate route to take a temperature on an infant.
Assessment
Application
Objective – 3
Page – 108
Difficulty – 3
18) A nurse educator is preparing an in-service on pain management for the staff. One of the staff nurses asks what the most important part of a pain assessment would be. What is the most appropriate response by the nurse educator?
1) “Pain is only partially subjective and primarily a physiological experience, so vital signs are the most important assessment.”
2) “A client’s response to pain is always based on the underlying cause, so the admission diagnosis is important.”
3) “If you observe the client sleeping, they are not experiencing very much pain.”
4) “The response to pain is unique and based on numerous factors which need to be assessed.”
18) 4
Explanation:
- Pain is entirely subjective and a personal experience. Vital signs are less important in pain assessment.
- Pain is a unique experience and is whatever the person says it is.
- Pain is a subjective and personal experience. The nurse should not rely on observations to give an accurate assessment.
- Pain is a subjective experience, and the response is unique to each individual. The factors which impact the response are numerous and include age, sex, culture, and developmental level, as well as previous experience with pain and health status. As nurses, a patient’s level of pain cannot be determined by their physiologic response only.
Assessment
Comprehension
Objective – 3
Page – 108, 109, 110
Difficulty – 2
19) A nurse observes the client walking into the room and climbing up on the examination table. What aspect of the general survey has the nurse completed?
1) Mobility status
2) Subjective assessments related to ambulation
3) Activity tolerance
4) Strength of upper and lower extremities
19) 1
Explanation:
- During a general survey, the nurse observes the client performing routine activities. This allows the nurse to begin to gather data about the client’s mobility. This data will then be incorporated into the remainder of exam and history.
- Observation is considered objective and not subjective.
- The purpose of this is not to observe tolerance to activity.
- This does not assess strength in the upper and lower limbs.
Assessment
Application
Objective – 2
Page – 99, 100
Difficulty – 1
20) How can a nurse assess a client’s mental status within the general survey?
1) Observe the client walking into the examination room.
2) Ask the client to describe elements of his health history.
3) Study the client’s clothing selections.
4) Notice the client’s ability to make eye contact during the examination.
20) 2
Explanation:
- Observing the client walking into the examination room would help assess mobility.
- The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and client behaviour. Asking the client to describe elements of his health history would help assess mental status.
- Studying the client’s clothing selections would help assess physical appearance.
- Noticing the client’s ability to make eye contact would help assess client behaviour.
Planning
Application
Objective – 2
Page – 100
Difficulty – 1
21) During a physical assessment the client asks the nurse repeatedly, “Is everything ok?” What is the most appropriate interpretation of this client’s behaviour?
1) A poor self concept
2) Inappropriate affect
3) Effective body image
4) Anxiety
21) 4
Explanation:
- Evidence of a poor self concept would include poor personal hygiene practices.
- An inappropriate affect would be demonstrated by the client responding inappropriately to a situation, such as laughter when discussing the death of a pet.
- Body image would be assessed by the way the client is dressed.
- A client’s level of anxiety is reflected in speech, body language, and facial expressions. Repeatedly asking if “everything is ok” could be evidence of worry about the outcome of the examination.
Diagnosis
Analysis
Objective – 5
Page – 100
Difficulty – 2
22) Mrs. Davidson, 72 years old, has edema of her lower extremities despite being prescribed medication for this symptom. What should the nurse do first?
1) Discuss the finding with the client’s physician.
2) Provide the client with support hose.
3) Review the client’s current medications.
4) Document the finding in the medical record.
22) 3
Explanation:
- The nurse should complete Mrs. Davidson’s assessment before contacting the physician.
- Providing the client with support hose might not be beneficial or indicated at this time.
- The nurse should discuss Mrs. Davidson’s current medications because elderly clients might be prescribed multiple medications which can combine to produce dangerous side effects. The schedules for multiple medications may be confusing and result in overmedication, forgotten doses, negative side effects, or ineffectiveness of medication. Therefore, the nurse must conduct a thorough assessment of Mrs. Davidson’s medication schedule and history.
- Documenting the finding is important, however, it is not something that should be completed first.
Planning
Application
Objective – 5
Page – 101
Difficulty – 2
23) Mr. Cohan, 34 years old, tells the nurse that he is “180 cm. tall and weighs 91 kg.” Upon assessment the client is found to be 175 cm. tall with a weight of 101 kg. What does this discrepancy indicate about Mr. Cohan?
1) Does not have a scale at home
2) Self-image is not in sync with actual findings
3) Didn’t want to tell the truth
4) Trying to hide a chronic illness
23) 2
Explanation:
- The nurse has no way of knowing if Mr. Cohan has a scale at home to use or not.
- The best reason for the inconsistency is that Mr. Cohan has a different image of himself than what is objectively measurable.
- The inconsistency between reported height and weight and actual height and weight does not mean Mr. Cohan is being dishonest.
- There is no indication that this is true.
Diagnosis
Analysis
Objective – 5
Page – 101
Difficulty – 1
24) Mrs. Choi, 83 years old, says to the nurse, “I’m losing weight from my waist up but gaining it in my legs.” What would be an appropriate response?
1) “Subcutaneous tissue decreases in the upper body as a person ages.”
2) “Your diet must be working, to an extent.”
3) “This happens to everyone. Don’t worry about it.”
4) “Let’s talk about your diet to see why you’re gaining weight in your legs.”
24) 1
Explanation:
- The older client may appear thinner, even when properly nourished, because of loss of subcutaneous fat deposits from the upper body. Fat deposits on the abdomen and hips may increase.
- The nurse should not assume the client has been on a diet or has changed his/her diet.
- The nurse should not make generalized statements nor should the nurse tell the client to be unconcerned.
- The loss of upper body weight and the increase in mass in the legs is not related to diet.
Implementation
Analysis
Objective – 2
Page – 102
Difficulty – 2
25) A resident in an extended care facility had a low body temperature in the morning and has a higher temperature at 19h00. What does this variation in temperature indicate?
1) The morning temperature was assessed incorrectly
2) The resident is developing an infection
3) The resident is experiencing stress
4) The temperatures reflect diurnal variations
25) 4
Explanation:
- There is no evidence to suggest the morning temperature was not assessed correctly.
- There is no evidence that the resident is developing an infection other than the higher evening body temperature.
- There is no evidence that the resident is experiencing stress other than the higher evening body temperature.
- The difference in body temperature is evidence of diurnal variation. Core body temperature is lowest during the early morning and becomes higher during the course of the day.
Diagnosis
Analysis
Objective – 4
Page – 103
Difficulty – 1
26) During the assessment of a client with abdominal pain, the nurse assesses a lower than normal blood pressure and a rapid pulse. What would these findings suggest to the nurse?
1) The client is a child and these are normal findings.
2) The client could have an abdominal infection.
3) The client is anxious.
4) The client’s medications are causing the blood pressure to be low.
26) 2
Explanation:
- The average pulse rate of infants and children is higher than that of teens and adults, there is no evidence to suggest this client is a child.
- The best selection is the client could have an abdominal infection since the client is experiencing abdominal pain in addition to the low blood pressure and elevated pulse rate.
- The pulse rate increases in response to stress, fear, and anxiety, however there is no evidence to suggest this client is anxious.
- There is also no information to suggest any of the client’s medications are causing the low blood pressure and higher than normal pulse.
Diagnosis
Analysis
Objective – 4
Page – 104
Difficulty – 3
27) In taking a client’s blood pressure, the nurse assessed the following: First sound heard: 136; Swishing sounds: 120; Tapping sounds: 100; Muffled sounds: 98; Sounds stop: 76. What blood pressure would the nurse document?
1) 136/76 mm Hg
2) 120/76 mm Hg
3) 120/98 mm Hg
4) 136/98 mm Hg
27) 1
Explanation:
- The first sound is recorded as the systolic blood pressure and the last sound is recorded as the diastolic blood pressure.
- The systolic blood pressure is the point at which the first sound is heard.
- The systolic blood pressure is the point at which the first sound is heard and the diastolic blood pressure is the last sound that is heard..
- The diastolic blood pressure is the last sound that is heard.
Implementation
Comprehension
Objective – 3
Page – 108 (Box 7.1)
Difficulty – 1
28) What location should the nurse use to assess the pulse of an 11-month-old infant?
1) The femoral artery
2) The brachial artery
3) The apical site
4) The radial artery
28) 3
Explanation:
- The femoral artery is not the most reliable site for taking a pulse in an infant.
- The brachial artery is not reliable for taking an infant’s pulse.
- The apical site is the site of choice to assess the pulse rate of a child who is under 2 years of age.
- The radial artery may be difficult to palpate in an infant.
Implementation
Application
Objective –3
Page – 104
Difficulty – 1
29) Mrs. Wayne, 42 years old, has pain due to spinal stenosis. She identifies her current pain level to be 5 on a scale from 0 to 10. Mrs. Wayne’s vital signs are all within normal limits. What does this indicate about Mrs. Wayne’s pain?
1) Less than she is rating.
2) A defense mechanism.
3) Worse than she is rating.
4) Ongoing, yet controlled with coping mechanisms.
29) 4
Explanation:
- Pain is an entirely subjective and personal experience. The nurse should not assume the client is experiencing less pain then is reported.
- There is no evidence to suggest the client is using pain as a defense mechanism
- Pain is an entirely subjective and personal experience. The nurse should not assume the client is experiencing more pain than is reported.
- The best conclusion for the nurse to make is this client’s pain is ongoing; however the client has effective coping strategies which aid in the control of the pain.
Diagnosis
Analysis
Objective – 5
Page – 109
Difficulty – 1
30) Mr. Fitzhugh, 68 years old, has been admitted for elective surgery. The nurse notes he is overweight, walks with a slight limp, has difficulty hearing the nurse’s questions, and his breathing appears to be laboured. What should the nurse do first?
1) Review his nutritional intake
2) Do a height and weight
3) Use an otoscope to assess his ears
4) Complete a respiratory assessment
30) 4
Explanation:
- Although the nurse may want to review Mr. Fitzhugh’s food intake, it is not the priority.
- Height and weight are not the priority when Mr. Fitzhugh has difficulty breathing.
- An ear assessment would not be a priority at this time.
- As Mr. Fitzhugh has laboured breathing, the nurse needs to complete a respiratory assessment in the event he needs oxygen.
Diagnosis
Analysis
Objective – 5
Page – 99
Difficulty – 3
SHORT ANSWER. Write the word or phrase that best answers the question.
31) A client appears disheveled in appearance, with uncoordinated clothes, body odor, and uncombed hair. What would the nurse assess during the history and physical exam? (Select all that apply.)
__ Anxiety
__ Depression
__ Mental illness
__ Self concept
31)
X_ Anxiety
X_ Depression
X_ Mental illness
X_ Self concept
Explanation:
The way a client dresses and maintains physical hygiene may provide clues to sense of self-esteem and body image as well as be an indicator of mental illness, anxiety, or depression.
Assessment
Analysis
Objective – 1
Page – 100
Difficulty – 1
