Health Promotion and Disease Prevention (MODULE 2) | 50 Questions And
Answers
A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the
nurse places the stethoscope over: Correct Ans ➡ The peripheral lung fields
Rationale: Vesicular breath sounds are heard over the peripheral lung fields, where air flows
through the smaller bronchioles and alveoli. Bronchovesicular breath sounds are heard over the
major bronchi. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Breath
sounds are not heard over the xiphoid process.
A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the
client's pulse is normal. Which of the following notations would the nurse make in the client's
record to document the force of the client's pulse? Correct Ans ➡ 2+
Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry
of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A
4-point scale may be used to assess the force (amplitude) of the pulse: 4+, bounding pulse; 3+,
increased pulse; 2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the client's
pulse as 2+.
Performing an abdominal assessment, a nurse auscultates before palpating and percussing the
abdomen. The nurse performs the assessment in this manner because: Correct Ans ➡
Palpation and percussion can increase peristalsis
Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after
inspection. Auscultation is done before palpation and percussion because these assessment
techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. The
other options identify incorrect reasons for auscultating the abdomen before palpating and
percussing it.
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? Correct Ans ➡
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.
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? Correct Ans ➡
Follow-up
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.
A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells
the client that this test measures: Correct Ans ➡ Peripheral vision
Rationale: The confrontation test is a gross measure of peripheral vision. It compares the client's
peripheral vision with the nurse's, assuming that the nurse's vision is normal. The nurse positions
himself or herself at eye level with the client, about 2 feet away, then directs the client to cover
one eye with an opaque card and look straight at the nurse with the other eye. The nurse covers
the eye opposite the client's covered one. The nurse then holds a pencil or flicking finger as the
target, midline between the nurse and the client, and slowly advances it from the periphery in
several directions. The nurse asks the client to say "now" as the target is first seen. This should
occur just as the nurse sees the object. Near vision is tested with a handheld vision screener that
contains various sizes of print. Color vision is tested with the use of the Ishihara test, which
comprises a series of cards bearing a pattern of dots printed against a background of many
colored dots. Distant vision is tested with the use of a Snellen chart.
A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse
take before inserting the otoscope? Correct Ans ➡ 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.
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?
Correct Ans ➡ 3+ 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.
A nurse is preparing to assess the function of a client's spinal accessory nerve. Which of the
following actions does the nurse ask the client to take to aid assessment of this nerve? Correct
Ans ➡ Shrugging the shoulders against the nurse's resistance
, Rationale: To assess cranial nerve XI (spinal accessory nerve), the examiner checks the
sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the
client to rotate the head forcibly against resistance applied to the side of the chin and by asking
the client to shrug the shoulders against resistance. These movements should feel equally strong
on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial
nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve
V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial
nerve IX (glossopharyngeal nerve).
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:
Correct Ans ➡ 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.
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? Correct
Ans ➡ Hypertension
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.
A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client
to repeat words that are: Correct Ans ➡ Whispered by the nurse from the client's side at a
distance of 1 to 2 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.
Answers
A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the
nurse places the stethoscope over: Correct Ans ➡ The peripheral lung fields
Rationale: Vesicular breath sounds are heard over the peripheral lung fields, where air flows
through the smaller bronchioles and alveoli. Bronchovesicular breath sounds are heard over the
major bronchi. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Breath
sounds are not heard over the xiphoid process.
A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the
client's pulse is normal. Which of the following notations would the nurse make in the client's
record to document the force of the client's pulse? Correct Ans ➡ 2+
Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry
of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A
4-point scale may be used to assess the force (amplitude) of the pulse: 4+, bounding pulse; 3+,
increased pulse; 2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the client's
pulse as 2+.
Performing an abdominal assessment, a nurse auscultates before palpating and percussing the
abdomen. The nurse performs the assessment in this manner because: Correct Ans ➡
Palpation and percussion can increase peristalsis
Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after
inspection. Auscultation is done before palpation and percussion because these assessment
techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. The
other options identify incorrect reasons for auscultating the abdomen before palpating and
percussing it.
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? Correct Ans ➡
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.
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? Correct Ans ➡
Follow-up
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.
A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells
the client that this test measures: Correct Ans ➡ Peripheral vision
Rationale: The confrontation test is a gross measure of peripheral vision. It compares the client's
peripheral vision with the nurse's, assuming that the nurse's vision is normal. The nurse positions
himself or herself at eye level with the client, about 2 feet away, then directs the client to cover
one eye with an opaque card and look straight at the nurse with the other eye. The nurse covers
the eye opposite the client's covered one. The nurse then holds a pencil or flicking finger as the
target, midline between the nurse and the client, and slowly advances it from the periphery in
several directions. The nurse asks the client to say "now" as the target is first seen. This should
occur just as the nurse sees the object. Near vision is tested with a handheld vision screener that
contains various sizes of print. Color vision is tested with the use of the Ishihara test, which
comprises a series of cards bearing a pattern of dots printed against a background of many
colored dots. Distant vision is tested with the use of a Snellen chart.
A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse
take before inserting the otoscope? Correct Ans ➡ 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.
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?
Correct Ans ➡ 3+ 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.
A nurse is preparing to assess the function of a client's spinal accessory nerve. Which of the
following actions does the nurse ask the client to take to aid assessment of this nerve? Correct
Ans ➡ Shrugging the shoulders against the nurse's resistance
, Rationale: To assess cranial nerve XI (spinal accessory nerve), the examiner checks the
sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the
client to rotate the head forcibly against resistance applied to the side of the chin and by asking
the client to shrug the shoulders against resistance. These movements should feel equally strong
on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial
nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve
V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial
nerve IX (glossopharyngeal nerve).
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:
Correct Ans ➡ 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.
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? Correct
Ans ➡ Hypertension
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.
A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client
to repeat words that are: Correct Ans ➡ Whispered by the nurse from the client's side at a
distance of 1 to 2 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.
