VNSG 1423 EXAM 2 QUESTIONS WITH
100% CORRECT ANSWERS
The nurse is conducting an assessment on the integumentary system and notes that
the client's skin on the right arm is blueish purple and the left arm is greenish yellow.
The nurse documents: - Answer- right arm has ecchymosis and the left arm has
resolved ecchymosis
As a component of a head to toe assessment, the nurse is preparing to assess
consensual response of the client eyes. How should the nurse conduct his assessment?
- Answer- Shine the pen light in the eyes to observe constriction of both pupils
A nurse is entering a client's room who recently had a repair of a fractured hip. The
client tells the nurse, "I have had a lot of pain in my abdomen." What type of
assessment would the nurse conduct? - Answer- Focused assessment
A nurse is planning to conduct vision screening as part of a health assessment. What
equipment would be needed to test vision? - Answer- Snellen chart
A nurse is using inspection as an assessment technique. What does the nurse use
during inspection? - Answer- Use of an otoscope and penlight
Which of the following can a nurse assess by palpation? - Answer- Temperature, turgor,
edema
The client reports experiencing abdominal pain. The nurse auscultates the client
abdomen and hears gurgling sounds. What additional information does the nurse
assess about the gurgling sound? - Answer- Frequency
A nurse is beginning a head to toe assessment by assessing which element of the
procedure first? - Answer- Assessing the client's vital signs
Reminder devices that are used to help prevent falls include: - Answer- bolsters and
over bed table Ch 13 pg 208 & 209
The minimum data set (MDS) is used to: - Answer- collect essential information Ch 5 pg
93-94
, Which of the following assessment findings requires immediate intervention? - Answer-
Non blanchable erythema of both heels Ch 21 pg 408- 409 Box 21.5
A nurse is conducting a neurological assessment on a client. The client was unable to
remember the date and time, how would the nurse document the level of
consciousness? - Answer- AAOx3 to person, place and situation Ch 21 pg 397
When assessing the eyes of a client, which characteristic is commonly seen? - Answer-
Shinning a light in opposite eye both pupils will constrict Ch 21 pg. 398
The nurse is attempting to locate the pedal pulse on a client who has been admitted
following injury to the upper right leg. The nurse should palpate and document the
location of the pulse as: - Answer- On the dorsal surface of the foot Ch 17 & 21, pg 320
& 411
A nursing assistant reports that a resident has been found lying on the floor of the
bathroom. Prioritize the actions of the nurse from first priority (1) to last priority (4). -
Answer- ask if the patient is okay
assess vital signs
notify the supervisor
notify the physician
An appropriate intervention for a older, frail client who is at risk for falls is: - Answer- A 2
hours toileting schedule while the client is awake Ch 13, pg 207
Adequate circulation is present if the nail beds: - Answer- blanch on pressure and color
returns in 5 seconds Ch 21, pg 410
A nurse is assessing a client's thyroid gland as part of a comprehensive physical
examination. Which of the following findings should the nurse expect? Select all that
apply. (3/5) - Answer- feeling the thyroid ascend as the client swallows
inspection of the jugular veins for distention
palpating the thyroid in the lower half of the neck
hearing a bruit when auscultating the thyroid
visualizing the thyroid on inspection of the neck
pg 400
Which of the following findings should the nurse expect to hear when auscultating the
thorax (chest)? - Answer- bronchovesicular ch 21, pg 402
a nurse is preparing to auscultating a client's abdomen as part of a comprehensive
physical examination. Which of the following findings should the nurse expect? -
Answer- high pitched clicks ch 21, pg 407
100% CORRECT ANSWERS
The nurse is conducting an assessment on the integumentary system and notes that
the client's skin on the right arm is blueish purple and the left arm is greenish yellow.
The nurse documents: - Answer- right arm has ecchymosis and the left arm has
resolved ecchymosis
As a component of a head to toe assessment, the nurse is preparing to assess
consensual response of the client eyes. How should the nurse conduct his assessment?
- Answer- Shine the pen light in the eyes to observe constriction of both pupils
A nurse is entering a client's room who recently had a repair of a fractured hip. The
client tells the nurse, "I have had a lot of pain in my abdomen." What type of
assessment would the nurse conduct? - Answer- Focused assessment
A nurse is planning to conduct vision screening as part of a health assessment. What
equipment would be needed to test vision? - Answer- Snellen chart
A nurse is using inspection as an assessment technique. What does the nurse use
during inspection? - Answer- Use of an otoscope and penlight
Which of the following can a nurse assess by palpation? - Answer- Temperature, turgor,
edema
The client reports experiencing abdominal pain. The nurse auscultates the client
abdomen and hears gurgling sounds. What additional information does the nurse
assess about the gurgling sound? - Answer- Frequency
A nurse is beginning a head to toe assessment by assessing which element of the
procedure first? - Answer- Assessing the client's vital signs
Reminder devices that are used to help prevent falls include: - Answer- bolsters and
over bed table Ch 13 pg 208 & 209
The minimum data set (MDS) is used to: - Answer- collect essential information Ch 5 pg
93-94
, Which of the following assessment findings requires immediate intervention? - Answer-
Non blanchable erythema of both heels Ch 21 pg 408- 409 Box 21.5
A nurse is conducting a neurological assessment on a client. The client was unable to
remember the date and time, how would the nurse document the level of
consciousness? - Answer- AAOx3 to person, place and situation Ch 21 pg 397
When assessing the eyes of a client, which characteristic is commonly seen? - Answer-
Shinning a light in opposite eye both pupils will constrict Ch 21 pg. 398
The nurse is attempting to locate the pedal pulse on a client who has been admitted
following injury to the upper right leg. The nurse should palpate and document the
location of the pulse as: - Answer- On the dorsal surface of the foot Ch 17 & 21, pg 320
& 411
A nursing assistant reports that a resident has been found lying on the floor of the
bathroom. Prioritize the actions of the nurse from first priority (1) to last priority (4). -
Answer- ask if the patient is okay
assess vital signs
notify the supervisor
notify the physician
An appropriate intervention for a older, frail client who is at risk for falls is: - Answer- A 2
hours toileting schedule while the client is awake Ch 13, pg 207
Adequate circulation is present if the nail beds: - Answer- blanch on pressure and color
returns in 5 seconds Ch 21, pg 410
A nurse is assessing a client's thyroid gland as part of a comprehensive physical
examination. Which of the following findings should the nurse expect? Select all that
apply. (3/5) - Answer- feeling the thyroid ascend as the client swallows
inspection of the jugular veins for distention
palpating the thyroid in the lower half of the neck
hearing a bruit when auscultating the thyroid
visualizing the thyroid on inspection of the neck
pg 400
Which of the following findings should the nurse expect to hear when auscultating the
thorax (chest)? - Answer- bronchovesicular ch 21, pg 402
a nurse is preparing to auscultating a client's abdomen as part of a comprehensive
physical examination. Which of the following findings should the nurse expect? -
Answer- high pitched clicks ch 21, pg 407
