HESI Extra Credit Module 2 Exam Health Promotion and Disease Prevention [NEW!!] 2022 (101 Pages).

HESI Extra Credit Module 2 Exam Health Promotion and Disease Prevention [NEW!!] 2022 (101 Pages) HESI Extra Credit Module 2 Exam Health Promotion and Disease Prevention [NEW!!] 2022 (101 Pages) A nurse performing a physical assessment of a client gathers both subjective and objective data. Which of the following findings would the nurse document as subjective data? The client appears anxious. The client has diminished reflexes in the legs. Blood pressure is 170/80 mm Hg. The client states that he has a rash. Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike and include data that the nurse would obtain during the physical examination. Review the difference between subjective and objective data if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? The client takes acetaminophen (Tylenol) for headaches. The client is allergic to strawberries. The last menstrual period was 30 days ago. A 1 × 2-inch scar is present on the lower right portion of the abdomen. Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike and include data that the nurse would obtain from the client during the health history. Review the difference between subjective and objective data if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? Emergency Episodic Complete Follow-up Rationale: A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting such as a pediatric or family practice clinic, an independent or group private practice, a college health service, a women’s healthcare agency, a visiting nurse agency, or a community health agency. An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or one body system. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed. Test-Taking Strategy: Use the process of elimination. Noting the words “initial home visit” in the question will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p.8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting: Data related to the respiratory system Data related to the treatment for the cold A complete (total health) database Data related to follow-up care Rationale: An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client s current and past state of health and forms a baseline against which all future changes can be measured. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question and noting the words now complaining of chest congestion and cough will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room Collect health history information first, then perform the physical examination Collect all information requested on the history form, including social support, strengths, and coping patterns Ask health history questions while performing the examination and initiating emergency measures Rationale: If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client s immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and note the words alert and cooperative. Noting that the client has not sustained life-threatening injuries will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? Emergency Follow-up Problem-centered Complete (total) Rationale: A follow-up database is compiled to evaluate the status of an identified problem at regular and appropriate intervals. An emergency database calls for rapid collection of the data, often at the same time lifesaving measures are being performed. A complete database includes a complete health history and a full physical examination. It describes the client s current and past state of health and forms a baseline against which all future changes can be measured. An episodic database (problem-centered) is compiled for a limited or short-term problem. It is focused mainly on one problem or body system. Test-Taking Strategy: Focus on the data in the question. Noting the words at the clinic for a check-up in the question will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands that the primary purpose of including cultural information in the health assessment is to: Identify any hereditary traits related to the epilepsy Confirm the medical diagnosis Make accurate nursing diagnoses Determine what the client believes has caused the epilepsy Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican-American culture, epilepsy is seen as a reflection of physical imbalance. Although the nurse may obtain data related to family history (hereditary) and formulate nursing diagnoses, these are not the primary reasons for including cultural information in the health assessment. A nurse gathers assessment data but does not confirm a medical diagnosis. Test-Taking Strategy: Use the process of elimination. Eliminate the option that indicates to confirm a medical diagnosis, because this is not the role of the nurse. To select from the remaining options, recall that cultural beliefs exist in relation to the cause of a disease; this will direct you to the correct option. Review the nurse s role in data collection and cultural considerations if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 52). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Cultural Diversity A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse determines that: The client needs to drink additional fluids The client needs to have the blanket removed The skin temperature is normal The client has a fever Rationale: To assess skin temperature, the nurse would first note the temperature of his or her own hands, then use the backs (dorsa) of the hands to palpate the client s skin bilaterally. The skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. The hands and feet may feel slightly cooler in a cool environment. Giving the client additional fluids, removing the blanket, and checking for a fever are all incorrect responses to this finding. Test-Taking Strategy: Focus on the data in the question. Note the word warm. Recalling that warmth suggests normal circulatory status will direct you to the correct option. Review normal skin temperature if you had difficulty with this question. References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 467). St. Louis: Saunders. Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 232). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Integumentary A nurse performing a skin assessment notes that the client's skin is very dry. The nurse documents this finding as: Seborrhea Xerosis Actinic keratoses Pruritus Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Causes include too- frequent bathing, low humidity, and decreased production of sebum in aging skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin. Seborrhea is one of several common skin conditions in which an overproduction of sebum results in excessive oiliness or dry scales. Actinic keratoses are red-tan scaly plaques that grow over the years, becoming raised and roughened. A silvery-white scale may adhere to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. Actinic keratoses are premalignant and may develop into squamous cell carcinoma. Test-Taking Strategy: Knowledge of the characteristics of various skin conditions and lesions is needed to answer this question. This knowledge and noting the words “very dry” in the question will direct you to the correct option. Review the conditions identified in the options if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 465, 480). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Integumentary A nurse is preparing to perform a skin examination with the use of a Wood light. In preparing for this diagnostic test, the nurse should: Obtain a scalpel and a slide for diagnostic evaluation Darken the room Obtain medication to anesthetize the skin area before proceeding with the examination Obtain informed consent from the client Rationale: A handheld long-wavelength ultraviolet (black) light, or Wood light, is sometimes used during physical examination of the skin. Areas of blue-green or red fluorescence are associated with certain skin conditions. Hypopigmented skin appears more prominent when it is viewed under black light, greatly facilitating the evaluation of pigment changes in fair-skinned clients. Examination of the skin is always carried out in a darkened room. The test is noninvasive, and the nurse should reassure the client that no discomfort is associated with a Wood light examination. Test-Taking Strategy: Use the process of elimination and focus on the name of the test. Recalling that this test is noninvasive will assist you in eliminating the incorrect options. Review the procedure for performing a Wood light test if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 477). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Adult Health/Integumentary A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding as: Ecchymosis Increased vascularity of the skin tissue Anasarca Unilateral edema Rationale: Bilateral edema, or edema that is generalized over the entire body, is known as anasarca. This finding is indicative of a central problem such as congestive heart failure or kidney failure. It does not indicate increased vascularity of skin tissue. Ecchymosis is a large patch of capillary bleeding into the tissues (bruise). Test-Taking Strategy: Use the process of elimination. Focusing on the words appearance of generalized edema in the question and visualizing the appearance of each condition in the options will help you answer correctly. Review the terms related to edema if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 714). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Renal A nurse reviewing the medical record of a client with the diagnosis of heart failure notes documentation indicating that the client has deep pitting edema, that the indentation remains for a short time, and that the leg looks swollen. How does the nurse document this finding? 1+ edema 2+ edema 3+ edema 4+ edema Rationale: Edema, the accumulation of fluid in the intercellular spaces, is not normally present. To check for edema, the nurse presses his or her thumbs firmly against the ankle malleolus or the tibia. Normally the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is present. Its presence is graded on the following 4-point scale: 1+ denotes mild pitting and slight indentation but no perceptible swelling of the leg, 2+ indicates moderate pitting in which the indentation subsides rapidly, 3+ indicates deep pitting in which the indentation remains for a short time and the leg looks swollen, and 4+ denotes very deep pitting in which the indentation lasts a long time and the leg is very swollen. Test-Taking Strategy: Focus on the data in the question. Noting the words indentation remains for a short time in the question will help direct you to the correct option. Review the grading scale for edema if you had difficulty with this question. References: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 233). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 569). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Cardiovascular A client complains that her skin is redder than normal. The nurse assesses the client’s skin, documents hyperemia, and explains to the client that this condition is caused by: Contraction of the underlying blood vessels A reduced amount of bilirubin in the blood Excess blood in the dilated superficial capillaries Diminished perfusion of the surrounding tissues Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. A reduced amount of bilirubin in the blood, diminished perfusion of the surrounding tissues, and contraction of the underlying blood vessels are all incorrect explanations for hyperemia. Test-Taking Strategy: Use the process of elimination. Note the relationship between the words “skin is redder” in the question and “excess blood” in the correct option. Review the description and cause of hyperemia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 312, 839). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which of the following actions does the nurse take to help ensure the success of the interview? Select all that apply. Having the client sit across a desk or table to give the client some personal space Maintaining a distance of 2 feet or closer between the nurse and client Seeing that distracting objects are removed from the room Ensuring that the room is private Switching on a dim light that will make the room cozier and help the client relax Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained, that there are no interruptions during the interview, that the room temperature is comfortable, that lighting is sufficient, that ambient noise is reduced, and that distracting objects are removed from the room. The nurse also ensures that the client and nurse are seated comfortably, eye to eye, without a desk or table between them, because a desk or table would act as a barrier. The nurse should maintain a distance of 4 to 5 feet from the client to avoid invading the client s private space, which might create anxiety on the part of the client. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike and involves personal space (2 feet or closer and the client sits across a desk or table). To select from the remaining options, recall that adequate lighting is important for the nurse to observe the client during the interview and a private room without distractions is important. Review the physical environment and its effect on a client interview if you had difficulty with this question. References: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 57). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 236-239). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Health Assessment/Physical Exam A nurse conducting an interview with a client collects subjective data. During the interview, the nurse: Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors Takes notes because this allows the nurse to break eye contact with the client, which may increase the client's level of comfort Takes notes to allow the nurse to shift attention away from the client, which may make the nurse more comfortable Takes a great deal of notes to allow the client to continue at his or her own pace as the nurse records what he or she is saying Rationale: During an interview, the nurse keeps note-taking to a minimum and tries to focus his or her attention on the client. Any note-taking should be secondary to the dialogue and should not interfere with the client s dialogue. Note-taking during an interview breaks eye contact too often; shifts the nurse s attention away from the client, diminishing his or her sense of importance; interrupts the client s narrative flow; impedes the nurse s observation of the client s nonverbal behaviors; and may be threatening to the client during the discussion of sensitive issues. Test-Taking Strategy: Use the process of elimination. Noting the word minimal will direct you to the correct option. Review the nurse s role with regard to note-taking during an interview if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 57). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 236-239). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam A nurse is preparing to screen a client’s vision with the use of a Snellen chart. The nurse: Asks the client to stand 40 feet from the chart and read the largest line on the chart Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision Assesses both eyes together, then assesses the right and left eyes separately Tests the right eye, then tests the left eye, and finally tests both eyes together Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot with the chart at the client’s eye level. The client is positioned on a mark exactly 20 feet from the chart. The client uses an opaque card to shield one eye at a time during the test; after each eye is tested, both eyes are assessed together. The client is asked to read through the chart to the smallest line of letters he or she can discern. The client is encouraged to read the next smallest line as well. Therefore the other options are incorrect. Test-Taking Strategy: Focus on the subject, a vision screening test. Visualizing each of the descriptions in the options will direct you to the correct one. Review the procedure for using the Snellen eye chart if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. ). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. The nurse interprets this to mean that the client: Is legally blind Can read at a distance of 20 feet what a client with normal vision can read at 80 feet Can read at a distance of 80 feet what a client with normal vision can read at 20 feet Has normal vision Rationale: When recording the results of visual acuity testing with the use of the Snellen chart, the nurse would use the numeric fraction noted at the end of the last line on the chart read successfully by the client. The top number (numerator) indicates the distance the client is standing from the chart; the denominator is the distance at which a normal eye could have read that particular line. Therefore a reading of 20/80 means that the client can read at a distance of 20 feet what a client with normal vision can read at 80 feet.. Legal blindness is defined as the best corrected vision in the better eye of 20/200 or worse. Normal visual acuity is 20/20. Test-Taking Strategy: Use the process of elimination. Recalling that the client stands 20 feet from the Snellen chart when visual acuity is being tested will direct you to the correct option. Review the procedure for interpreting the results from this visual acuity test if you had difficulty with this question. References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1686). St. Louis: Saunders. Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 308-309). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is examining the peripheral vision of a client using the confrontation test. To carry out this procedure, the nurse: Asks the client to discriminate numbers on a chart composed of colored dots Darkens the room and asks the client to identify colored blocks and shapes that appear in the visual field Has both the client and nurse cover the right eye, stare at each other's uncovered eye, and bring a small object into the visual field, then repeat the test with the left eye Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field Rationale: The confrontation test is a gross measure of peripheral vision. It compares the client’s peripheral vision with the examiner’s vision under the assumption that the examiner’s vision is normal. The examiner positions himself or herself at eye level with the client, about 2 feet away. The examiner directs the client to cover one eye with an opaque card and look straight at the examiner with the other. The examiner covers his or her own eye opposite the client’s covered one. Next the examiner holds a pencil or flicking finger as a target midline between himself or herself and the client and slowly advances it from the periphery in several directions. The examiner asks the client to say “now” as the target is first seen. This sighting should occur just as the examiner sees the object for the first time. Asking the client to discriminate numbers on a chart composed of colored dots and darkening the room and asking the client to identify colored blocks and shapes that appear in the visual field are both components of testing for color vision. Test-Taking Strategy: Use the process of elimination and recall that the confrontation test assesses peripheral vision. This will assist you in eliminating the options that do not address this concept. To select from the remaining options, visualize each. This will direct you to the correct option. Review this vision test if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 310). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse performing an eye examination uses an ophthalmoscope to best visualize which of the following areas? Iris Conjunctiva Optic disc Cornea Rationale: The ophthalmoscope enlarges the examiner s view of the eye so that the media (anterior chamber, lens, vitreous humor) and the ocular fundus (the internal surface of the retina) can be examined. The optic disc is located on the internal surface of the retina. The iris, conjunctiva, and cornea can be examined without the use of an ophthalmoscope. Test-Taking Strategy: Think about the anatomical structures of the eye. Recalling that the optic disc is located on the internal surface of the retina will direct you to the correct option. Review the structures that need to be examined with the use of an ophthalmoscope if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing(7th ed., p. 580). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that the client has normal: Central vision Near vision Peripheral vision Ocular movements Rationale: Leading the client’s eyes through the six cardinal fields of gaze will elicit any muscle weakness during movement. This test assesses the function of the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Near vision is tested with the use of a handheld vision screener that contains various sizes of print. Central vision is measured with the use of a Snellen chart. Peripheral vision is measured with the confrontation test. Test-Taking Strategy: Use the process of elimination. Recalling that the six cardinal fields of gaze are used to test for muscle weakness will direct you to the correct option. Also note the relationship of the words “moved” in the question and “movements” in the correct option. Review this test if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. ). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Eye A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as: Ptosis Exophthalmos Scleral icterus Nystagmus Rationale: Nystagmus is a fine oscillating movement, most notable around the iris. The nurse checks for nystagmus when assessing a client for ocular muscle weakness. Mild nystagmus at extreme lateral gaze is normal; nystagmus at any other position is not. Ptosis is a drooping of the eyelid. Scleral icterus is a yellowing of the sclera, extending up to the cornea, that indicates jaundice. Exophthalmos, a noticeable protrusion of the eyeball, is a characteristic sign of hyperthyroidism. Test-Taking Strategy: Use the process of elimination. Recalling that exophthalmos is a protrusion of the eyeball associated with hyperthyroidism will assist you in eliminating this option. To select from the remaining options, focus on the words “oscillating movements” in the question and read each option carefully to find the correct one. Review the description of nystagmus if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. ). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Eye A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding? Photophobia Hyperopia Myopia Accommodation Rationale: Accommodation is adaptation of the eye for near vision. Movement of the ciliary muscles increases the curvature of the lens. To observe accommodation, the examiner notes convergence (motion toward) of the axes of the eyeballs and pupillary constriction. Myopia is nearsightedness. Hyperopia is farsightedness. Photophobia is abnormal sensitivity to light, especially of the eyes. Test-Taking Strategy: Focus on the data in the question. Note the relationship between the data “pupils get larger” and “become smaller” in the question and the correct option. Review the description of accommodation if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 1074). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Eye A nurse is using an otoscope to examine the ears of a client. Which of the following findings indicates to the nurse that the tympanic membrane is normal? Rationale: The tympanic membrane is shiny and translucent, with a pearly gray color. The appearance of a yellow clump of material indicates the presence of a piece of cerumen in the external meatus. An excessive amount of cerumen in the external auditory canal appears dark and covers a large part of the canal and tympanic membrane. A hole in the tympanic membrane indicates perforation of the membrane. Test-Taking Strategy: Knowledge regarding the appearance of the tympanic membrane is needed to answer the question. It is necessary to recall that the normal tympanic membrane is pearly gray in color. Review the normal findings on otoscopic examination of the ear if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1673). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client? Exposure to cigarette smoke Use of power tools Occupational noise Loud music Rationale: Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include youth (otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. Loud music, the use of power tools, and occupational noise can all cause hearing loss. Hearing loss may occur as a result of an acute loud noise (acoustic trauma) or long-term exposure to loud noise (noise-induced hearing loss). Test-Taking Strategy: Use the process of elimination and focus on the word “infection” in the question. Eliminate the options that are comparable or alike and refer to noise. Review the causes of middle ear infections if you had difficulty with this question. Reference: Copstead, L., & Banasik, J. (2010). Pathophysiology (4th ed., p. 1092). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Ear A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse take before inserting the otoscope? Tipping the client's head down and away from the examiner Tipping the client's head down and toward the examiner Pulling the pinna down and forward Pulling the pinna up and back Rationale: In an adult client, the nurse pulls the pinna up and back to help straighten the S shape of the ear canal. The client’s head is tilted slightly away from the examiner, toward the client’s opposite shoulder. The nurse holds the pinna gently and firmly until the examination is complete and the otoscope has been removed from the client’s ear. The nurse pulls the pinna down when examining an infant or a child younger than 3 years. Test-Taking Strategy: Focus on the subject, examining the ear of an adult client with an otoscope. Visualize the descriptions in each of the options to direct you to the correct option. Review the procedure for using an otoscope if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 1115). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat words that are: Spoken in a soft tone of voice by the nurse about 5 feet in front of the client Whispered at a distance of 20 feet by the nurse while he or she is standing in front of the client Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested Spoken by the nurse from the client's side in a normal tone of voice about 10 feet from the ear being tested Rationale: In performing the voice test, the nurse tests one ear at a time while masking hearing in the other ear to prevent transmission around the head. The nurse shields his or her lips so that the client cannot compensate for hearing loss (consciously or unconsciously) by lip-reading or using the good ear. The nurse stands 1 to 2 feet from the client s ear, exhales, and slowly whispers some two-syllable words. A client with normal hearing repeats each word correctly. Test-Taking Strategy: Visualize each option. Eliminate the options that indicate that the nurse must stand in front of the client; if the nurse did this, the client would be able to lip-read. To select from the remaining options, note the words about 10 feet ; this will help you eliminate this option. Review the procedure for the voice test if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. ). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork? On the client's forehead On the midline of the client's skull On the client's mastoid bone On the client's teeth Rationale: In the Rinne test, the base of an activated tuning fork is held first against the mastoid bone, behind the ear, and then in front of the ear canal (0.5 to 2 inches). When the client no longer perceives the sound behind the ear, the fork is moved in front of the ear canal until the client indicates that the sound can no longer be heard. The client reports whether the sound from the tuning fork is louder behind the ear (on the mastoid bone) or in front of the ear canal. In the Weber test, an activated tuning fork is placed on the midline of the skull, the forehead, or the teeth. Test-Taking Strategy: Knowledge of the Rinne test is needed to answer this question. Visualizing the procedure for performing this test will direct you to the correct option. Review this hearing test if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 1116). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. The nurse, inspecting the ears for cerumen impaction, checks for: Redness and swelling of the tympanic membrane The presence of edema in the external auditory canal A yellowish or brownish waxy material in the external auditory canal An external auditory canal that is longer than normal Rationale: Cerumen (ear wax) is a yellowish or brownish waxy secretion produced by vestigial apocrine sweat glands in the external ear canal. It becomes impacted because of the narrow tortuous canal or as a result of poor cleaning methods. Cerumen may partially obscure the eardrum or totally occlude the ear canal. Even when the canal is 90% to 95% blocked, hearing is normal, but when the last 5% to 10% becomes occluded (e.g., when cerumen expands after the client swims or showers), the client experiences sudden hearing loss and a feeling of fullness in the ear. Redness and swelling of the tympanic membrane, edema in the external auditory canal, and an external auditory canal that is longer than normal are not descriptions of cerumen. Test-Taking Strategy: Use the process of elimination and focus on the word “cerumen” in the question. Recalling that cerumen is ear wax will direct you to the correct option. Review the characteristics of cerumen if you had difficulty with this question. References: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 344, 366). St. Louis: Saunders. Mosby’s Dictionary of medicine nursing & health professions (2009) (8th ed., p. 341). St. Louis: Elsevier. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is palpating a client's sinus areas. Which of the following sensations does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal? Pain behind the eyes Firm pressure Pain during palpation Pressure producing an acute headache Rationale: The client would normally feel a firm pressure as the nurse palpates his or her sinuses. Pain experienced during palpation of the sinuses is an indication of acute sinusitis. Headaches that vary in intensity with position changes or when secretions drain indicate acute sinusitis. An acute headache should not occur with palpation of the sinuses. Test-Taking Strategy: Note the strategic words if the sinuses are normal in the query of the question. Eliminate the options that are comparable or alike and indicate the presence of discomfort on palpation of the sinuses. Review the expected findings when palpating the sinuses if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1532). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is preparing to test the function of cranial nerve XI. Which of the following actions does the nurse take to test this nerve? Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex Depressing the client’s tongue with a tongue blade and noting pharyngeal function as the client says “ah.” Asking the client to stick out his or her tongue and watching the client for tremors Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size. The nurse checks that these muscles are equal in strength by asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse’s hands. Asking the client to stick out the tongue and watching for tremors is the method for assessing the function of cranial nerve XII (hypoglossal nerve). Assessment of pharyngeal function reveals the function of cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike and address pharyngeal function. To select from the remaining options, recall that cranial nerve XI is the spinal accessory nerve, which will direct you to the correct option. Review the procedure for assessing the function of cranial nerve XI if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1775). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve? An ophthalmoscope A wisp of cotton A tuning fork Coffee Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse tests the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client s nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client s eyes closed, the nurse occludes one nostril and presents a nonnoxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. A tuning fork is used to assess the function of cranial nerve VIII (acoustic nerve). A wisp of cotton is used to assess the sensory function of cranial nerve V (trigeminal nerve). An ophthalmoscope is used to assess the internal structures of the eye. Test-Taking Strategy: Use the process of elimination. Recalling that cranial nerve I is the olfactory nerve will direct you to the correct option. Review cranial nerve I and the method of testing its function if you had difficulty with this question. References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1775). St. Louis: Saunders. Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 666-667). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Health Assessment/Physical Exam A nurse inspecting a client s throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of: Cranial nerve XII Cranial nerve V Cranial nerves I and II Cranial nerves IX and X Rationale: The motor function of cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) is tested by depressing the tongue with a tongue blade and noting the pharyngeal movement as the client says ah. Motor function of these nerves is also tested by touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Eliciting a response from cranial nerve V (trigeminal nerve) tests the muscles of mastication. Eliciting a response from cranial nerve I (olfactory nerve) tests the function of smell. Eliciting a response from cranial nerve II (optic nerve) involves eye examinations. In testing cranial nerve XII (hypoglossal nerve), the examiner inspects symmetry and movement of the tongue. Test-Taking Strategy: Focus on the data in the question. Recalling that cranial nerve IX is the glossopharyngeal nerve and cranial nerve X is the vagus nerve will direct you to the correct option. Review these cranial nerves if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes. (8th ed., p. 1775). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing? Cranial nerve V Cranial nerve IX Cranial nerve X Cranial nerve XII Rationale: To test cranial nerve XII (hypoglossal nerve), the examiner inspects symmetry and movement of the tongue. The nurse looks for a forward thrust in the midline as the client sticks out the tongue. The examiner tests the motor function of cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve) by depressing the client’s tongue with a tongue blade and noting the pharyngeal movement as the client says “ah.” Motor function of these nerves is also tested by touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Eliciting a response from cranial nerve V (trigeminal nerve) tests the muscles of mastication. Test-Taking Strategy: Focus on the data in the question. Recalling that cranial nerve XII is the hypoglossal nerve will direct you to the correct option. Review the method of testing this cranial nerve if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1775). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is preparing to listen to the breath sounds of a client. The nurse should: Hold the bell of the stethoscope lightly against the chest Ask the client to breathe in and out through the nose Ask the client to lie prone Listen for at least one full respiration in each location on the chest Rationale: To best listen to breath sounds, the nurse asks the client to sit, leaning slightly forward, with the arms resting comfortably across the lap. The client is instructed to breathe through the mouth, a little deeper than usual, but to stop if he or she feels dizzy. The flat diaphragm endpiece of the stethoscope is held firmly against the client’s chest wall. The nurse listens for at least one full respiration in each location on the chest. Side-to-side comparison is most important in the assessment of breath sounds. Test-Taking Strategy: Use the process of elimination. Read carefully and visualize each of the options. Thinking about the procedure for listening to breath sounds and noting the words “one full respiration” will direct you to the correct option. Review the procedure for listening to breath sounds if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1534). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as: Abnormal vesicular breath sounds Normal whispered pectoriloquy Normal egophony Abnormal bronchophony Rationale: The quality of voice resonance can be performed by testing for the presence of bronchophony, egophony, and whispered pectoriloquy. In bronchophony, the nurse asks the client to repeat the word "ninety-nine" as the nurse listens to the client’s chest with a stethoscope. Normal voice transmission is soft, muffled, and indistinct. The nurse normally hears sound through the stethoscope but cannot distinguish exactly what is being said. A pathologic condition that increases lung density enhances the transmission of voice sounds; in such a case, the nurse will hear "ninety-nine" clearly. Vesicular breath sounds are heard over peripheral lung fields where air flows through smaller bronchioles and alveoli. In egophony, the client’s chest is auscultated while the client phonates a long "ee-ee-ee-ee" sound. Normally the nurse hears "eeeeee" through the stethoscope. In whispered pectoriloquy, the client is asked to whisper a phrase such as "one-two-three" as the nurse listens to the chest. The normal response is a muffled, almost inaudible sound. Test-Taking Strategy: Knowledge of the methods for determining the quality of breath sounds is needed to answer this question. For this question it is necessary to remember that in bronchophony normal voice transmission is soft, muffled, and indistinct. Review bronchophony, egophony, and whispered pectoriloquy and the normal findings if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 457). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam IncorrectQuestion 36 0 / 1 pts A nurse is preparing to check the breath sounds of a client. Over which anatomic area does the nurse place the stethoscope when auscultating for bronchial breath sounds? 1 4 2 3 Rationale: Bronchial (tracheal) breath sounds are located over the trachea and larynx. Bronchovesicular breath sounds are located over major bronchi. Vesicular breath sounds are located over the peripheral lung fields. The upper sternal area is where main bronchi are located. Breath sounds are normally not heard over the cricoid cartilage. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike. From the remaining options, recall that bronchial breath sounds are also noted as tracheal sounds; this will direct you to the correct option. Review the location of normal breath sounds if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 561, 562). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be? Rustling Harsh Tubular Hollow Rationale: Vesicular breath sounds are rustling and sound like wind blowing through trees. Bronchial (tracheal) breath sounds are harsh, hollow, tubular sounds. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike (tubular and hollow). In considering the remaining options, think about the location of vesicular breath sounds. This will help direct you to the correct option. Review the normal quality of vesicular breath sounds if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 562). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse sees documentation in the client's record indicating that the physician has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds are: Rustling sounds heard over the peripheral lung fields Abnormal sounds that should not be heard in the lungs Hollow sounds heard over the trachea and larynx Normally heard in the lungs Rationale: Adventitious breath sounds are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused when moving air collides with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds. Test-Taking Strategy: Note that two options are opposing statements (normally heard and abnormal sounds). This may indicate that one of these options is correct. From this point, recall the definition of adventitious and that adventitious breath sounds are abnormal. Review adventitious breath sounds if you had difficulty with this question. References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1536). St. Louis: Saunders. Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 562, 564). St. Louis: Saunders. Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Respiratory A nurse is assessing a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the nurse obtain data on from the client? Ethnicity Age Hypertension Genetic inheritance Rationale: Risk factors for CAD may be categorized as modifiable and unmodifiable. Unmodifiable risk factors include age, sex, ethnicity, genetic predisposition, and family history of heart disease. Modifiable risk factors include increased concentrations of serum lipids, hypertension, cigarette smoking, obesity, and level of physical activity. Contributing modifiable risk factors include diabetes mellitus and a stressful lifestyle. Test-Taking Strategy: Use the process of elimination and note the word “modifiable” in the query of the question. The only risk factor listed that can be changed is hypertension. Review modifiable and unmodifiable risk factors for CAD if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 850). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Cardiovascular A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment by: Palpating both arteries simultaneously to compare amplitude Listening to the carotid artery, using the bell of the stethoscope to assess for bruits Palpating the carotid artery in the upper third of the neck Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery Rationale: To assess the carotid artery, the nurse uses the techniques of palpation and auscultation. The nurse palpates each carotid artery medial to the sternomastoid muscle in the neck. The nurse should avoid putting pressure on the carotid sinus higher in the neck because of the risk of excessive vagal stimulation, which could slow the heart rate. The nurse should palpate one artery at a time to avoid compromising arterial blood flow to the brain. The nurse should auscultate each carotid artery for the presence of a bruit. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally a bruit is not present. The nurse should lightly place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath briefly so that tracheal breath sounds do not mask or mimic a carotid artery bruit. Test-Taking Strategy: Use the process of elimination. Palpating both arteries simultaneously will obstruct blood flow to the brain, so eliminate this option. Next, recalling the location of the carotid artery will assist you in eliminating the option that indicates that the nurse should palpate in the upper third of the neck. To select from the remaining options, eliminate the option that instructs the client to take slow, deep breaths, because this client action would prevent the nurse from hearing a bruit if one is present. Review the technique for assessing the carotid arteries if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 794-795). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Cardiovascular A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope at the: Second right interspace Fifth left interspace at the midclavicular line Second left interspace Left lower sternal border Rationale: The mitral valve is located in the area of the fifth left interspace, at the midclavicular line. The pulmonic valve is located in the area of the second left interspace. The aortic valve is located in the area of the second right interspace. The tricuspid valve is located in the area of the left lower sternal border. Test-Taking Strategy: Focus on the subject, the area in which the mitral valve is located. Visualizing the anatomy of the heart will direct you to the correct option. Review the anatomy of the heart and areas of auscultation of the heart valves if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 136). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips: In the groove between the malleolus and the Achilles tendon Behind the knee Lateral to