NR 302 Exam / NR302 Exam (Latest-2020): Health Assessment I: Chamberlain College of Nursing (Latest 2020, 100% Correct, Already graded A)

NR 302 Exam / NR302 Exam (Latest): Health Assessment I: Chamberlain College of Nursing The nurse is interviewing the client. The nurse states, "Can you tell me exactly how you feel when you are having difficulty catching your breath?" Which of the following types of communication techniques is the nurse utilizing specifically? -Attending -Focusing -Paraphrasing -Summarizing The client has been diagnosed with an early stage of wide-angle glaucoma. The nurse is performing a wellness assessment during the client's initial interview. Which of the following statements by the client may be elicited during this portion of the health history? (Select all that apply.) 1. "Sometimes, my eyes feel very tired and sort of ache." 2. "My husband and I have 3 couples that we would classify as our very good friends." 3. "I pay attention to the foods that I eat, because I want my body to stay well." 4. "My mom was diagnosed with glaucoma when she was 60 years old." 5. "I think I do a good job of managing stress with yoga every day and running three times a week." The nurse is obtaining a family health history when the client reports that a grandparent had type 1 diabetes. Where should the nurse document this information? 1. Present health/illness 2. Family genogram 3. Past medical history 4. Health practices The nurse is interviewing a client who is in acute pain. Which of the following actions by the nurse must be performed first? 1. Attempt to reduce the pain and complete the interview later. 2. Interview the family for the information. 3. Document why the interview could not be completed. 4. Proceed very quickly with the interview. The nurse is obtaining information about a client's past medical history. Which of the following sources would provide the nurse with this data? 1. Medication list 2. Average amount of hours of sleep each night 3. Marital status 4. Immunization records The nurse is interviewing the client. Which of the following techniques should the nurse use to decode the client's messages? 1. Use body language to convey the message. 2. Listen actively and attentively. 3. Develop and transmit an idea. 4. Use words to convey the message. While interviewing the client during the focused interview, the client begins to cry softly. Which of the following interventions by the nurse are appropriate? (Select all that apply.) 1. The nurse states, "I don't like these questions any more than you do, but we need to get on with the interview so you can go home and cry later." 2. The nurse states, "It's all right, I think we're done with the interview." 3. The nurse places the tissues within arm's reach of the client. 4. The nurse states, "I can see you are upset. It's all right to cry." 5. The nurse remains quiet until the nurse feels that the client is prepared to proceed with the interview. The student nurse is preparing to perform a health history interview. Which of the following statements indicate that the student nurse requires further education regarding the purpose of the health history? (Select all that apply.) 1. "The nurse typically has a more holistic point of view regarding the client's health." 2. "The client's health history can be gathered during the initial interview." 3. "The healthcare provider's and nurse's assessments should be almost identical with the same focus." 4. "I realize that the client is sick, but I also need to perform a wellness assessment." 5. "As the nurse, I will mainly focus on the course of the client's illness." The nurse is interviewing the client. The nurse says to the client, "It sounds like you don't like your new job because it's more stressful than you anticipated." Which of the following types of communication techniques is the nurse utilizing specifically? 1. Questioning 2. Paraphrasing 3. Attending 4. Listening The nurse is using a Doppler ultrasonic stethoscope to assess a client's pulse in the lower extremity and is unable to locate the pulse. What is the nurse's next action? 1. Send the equipment for repair. 2. Check the pressure applied to the probe. 3. Add more gel to the end of the probe. 4. Immediately inform the healthcare provider. A client is brought to the emergency department by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which of the following findings would indicate, to the nurse, the need for a more detailed neurological assessment of this client? 1. Talking in a loud voice 2. Asymmetry of the client's smile 3. Inability to follow directions 4. Grimacing with movement The nurse is assessing an adult client when suddenly the client refuses to continue the examination. What is the nurse's next step? 1. Give the client a short break and then resume the assessment. 2. Document what was done and what was refused. 3. Summon another nurse to the room to serve as a witness. 4. Enlist the assistance of the client's family to encourage the rest of the assessment. The nurse uses the otoscope in the physical assessment of a client. The nurse understands that this instrument is used to: (Select all that apply.) 1. Inspect the nose. 2. Inspect the internal structures of the eye. 3. Funnel light into the ear canal. 4. Detect fungal infections of the skin. 5. Assess pulses that are not palpable. The nurse is preparing a teaching plan regarding thyroid function for the older adult. Which of the following would the nurse include in this teaching? 1. Information on birth control 2. Information about congenital abnormalities 3. Annual monitoring of hormone levels 4. Eliminating the use of alcohol A client complains of daily headaches. Which of the following would the nurse include in the focused interview? (Select all that apply.) 1. "Have you had a recent cold or infection?" 2. "Is there anything that relieves the pain, like resting or medication?" 3. "Is the pain sharp, dull, steady, or throbbing?" 4. "Tell me exactly where the pain is located." 5. "Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst." The nurse is assessing the function of the client's cranial nerves. The nurse finds that the client is unable to demonstrate the ability to chew. The nurse suspects that which of the following cranial nerves is not functioning properly? 1. Cranial nerve VI (/Abducens) 2. Cranial nerve V (Trigeminal) 3. Cranial nerve III (Oculomotor) 4. Cranial nerve VII (Facial) The nurse is preparing an educational seminar about Healthy People 2020. The inclusion of which of the following topics in this presentation are unexpected and indicate that the nurse requires further education? (Select all that apply.) 1. Immigrants may have an increased risk of disorders related to thyroid function. 2. The iodine added to some medications can be linked to hypothyroidism in the clients who use these medications. 3. Depression in older adults may be linked to hypothyroidism. 4. Thyroid disease more frequently affects males than females. 5.The parents of a newborn should be educated about the clinical manifestations associated with hyperthyroidism. The nurse is assessing the 1-month-old infant's fontanels. The infant's fontanels are sunken. What may this indicate to the nurse? 1. Dehydration 2. Infection 3. Fetal Alcohol Syndrome 4. Thyroid disease Which of the following findings is normal regarding assessment of the fontanels? 1. The 1-month-old infant's posterior fontanel has closed. 2. The nurse notes that the 2-week-old infant's fontanels are slightly pulsing. 3. The 10-month-old infant's anterior fontanel is shaped like a triangle. 4.The 2-year-old child's anterior fontanel remains unclosed. The client presents with unilateral facial paralysis and the nurse suspects Bell's palsy. Which of the following statement by the nurse to the client may indicate that the nurse requires further education about Bell's palsy? 1. "This may have occurred as a result of a viral infection." 2. "Your cranial nerve VII is not functioning appropriately." 3. "This will probably disappear on its own in several weeks." 4. "The onset of Bell's palsy is very slow and the effects can linger for several months." The nurse is assessing the fundus of the elderly client's eye with an ophthalmoscope. The nurse determines that there is a cyst within the macula. Which of the following client symptoms may be associated with this finding? 1. Impaired central vision 2. Uncontrolled hypertension 3. Impaired peripheral vision 4. Consistently elevated serum glucose levels The nurse is completing a focused interview with assessment of the eye. Which of the following is most helpful to the nurse during the focused interview? 1. The client interacts easily with the nurse. 2. The client is an African American male. 3. The client graduated from college. 4. The client is 23 years old The nurse presented a program regarding objectives related to the overall health of eyes that are addressed in Healthy People 2020. Which of the following statements made by an adult participant in the program indicates an adequate understanding of these objectives? 1. "My mom has been complaining of dry eyes, but I knew it was all in her head." 2. "I'm going to call my eye doctor and ask that she performs a dilated eye exam." 3. "My 4-year-old doesn't need his vision screened." 4. "I didn't know that Asians have the highest risk for developing glaucoma." The nurse is preparing to assess the client's eye with an ophthalmoscope while a student nurse is observing. Which of the following statements by the nurse to the student nurse is accurate regarding this portion of the assessment? 1. "I'm going to advance the ophthalmoscope until the instrument touches the client's cornea." 2. "I'm going to examine the client's right eye with my left eye." 3. "I'm going to begin with the lens set to the 0 diopter." 4. "I can see the red reflex as the light reflects off of the client's lens." The nurse is assessing the eyes of an 82-year-old client. Which of the following findings are expected by the nurse based on the client's age? 1. The client is easily able to read from a paper held at close range without corrective glasses. 2. The client states that she feels her tear production has increased over the years. 3. There is a noticeable increase in fat within the orbit of the eye. 4. The pupillary light reflex is slower bilaterally. The client has been brought via ambulance to the emergency room following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. What is the nurse's priority nursing action? 1. Irrigate the ear with warm mineral oil, peroxide, and flush with warm water. 2. Request information from the client regarding any chronic allergies. 3. Test the drainage for glucose. 4. Ask the patient if she has experienced a recent middle ear infection. The nursing is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane. The nurse should perform which of the following steps to better visualize this structure? 1. Pull the pinna up and back, then reinsert the otoscope 2. Reinsert the otoscope quickly and press against both sides of the inner auditory canal. 3. Tell the client to move away from the speculum if they experience any pain as the otoscope is advanced. 4. Pull the pinna down and back, then reinsert the otoscope. The nurse is discharging an 11-month-old child who was brought to the emergency room for the treatment of an ear infection and fever. The nurse would include which of the following statements in the discharge teaching to the parents? (Select all that apply) 1. "You must perform oral hygiene more frequently throughout the day." 2. "The baby's last bottle before bedtime should only contain water." 3. "You must rinse the baby's mouth right after the baby falls asleep." 4. "It is important not to prop the baby's bottle during feeding." 5. "The last bottle of the evening should not be given just before the baby goes to sleep During the focused interview, the client admits to regularly abusing cocaine. Which of the following findings does the nurse expect to discover during the physical assessment of the client's nose? (Select all that apply.) 1. Yeast infection of nasal mucosa and in mouth 2. Temporomandibular joint pain when the client opens and closes the mouth 3. The septum is noted to be very pale in color. 4. Difficulty swallowing water 5. The nurse notes that the nasal septum has perforated. The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test was positive. As the nurse plans to meet the client's elimination needs, the nurse would implement which of the following interventions? 1. Allow the client to walk independently. 2. Obtain an order for a catheter. 3. Limit fluid intake. 4. Obtain a bedside commode. The nurse educates the client about the major functions of the nose and sinuses. Which of the following structures is specifically responsible for filtering, moistening, and warming air that enters the lower portion of the respiratory tract? 1. Nares 2. Columella 3. Turbinates 4. Olfactory cells True or False: The vestibule is made up of the lips, buccal mucosa, outer surface of the gums and the teeth and cheeks. The mouth is separated from the vestibule by the teeth. The mouth is made up of the tongue, hard and soft palate, uvula, mandibular arch, and axillary arch. True While the client sleeps, the nurse notes that the client's respirations periodically stop. This finding would be documented as: 1. Bradypnea. 2. Atelectasis. 3. Tachypnea. 4. Apnea. A client is demonstrating a diminished ability to exhale. The nurse realizes this client is at risk for developing: 1. Pleurisy. 2. Congestive heart failure. 3. Reduced oxygen capacity. 4. Increased carbon dioxide levels True or False: The right main bronchus is shorter, wider, and more vertical than the left bronchus; therefore, aspirated objects are more likely to enter the right lung. True The nurse is preparing to assess the client's respiratory system. Rank in order according to how the nurse should proceed: Auscultation, Client Survey, Palpation, Inspection, Percussion 1. Client survey 2. Inspection 3. Palpation 4. Percussion 5. Auscultation The nurse is examining a client who has been diagnosed with a fracture of one floating rib. Of the following ribs, which does the nurse suspect to be fractured? --5 --9 --1 --12 The nurse is preparing an educational program regarding Healthy People 2020. Which of the following pieces of information is important to include for caregivers of infants and young children? (Select all that apply.) 1. "Parents should be educated about the importance of immunizations." 2. "Children should be taught to wash their hands." 3. "Caregivers should inspect the children's toys for small possibly inhalable parts." 4. "Infants should always be placed to sleep on their backs." 5. "Caregivers should ensure that the children's toys are age-appropriate." The nurse is assessing the client's respiratory system. Which of the following methods will result in the most accurate assessment of the client's respiratory rate? 1. The nurse should count only the respirations that are audible. 2. The nurse should count the respirations in an unobtrusive manner without informing the client. 3. The nurse should inform the client that the nurse is counting the client's respirations. 4. The nurse should place a hand on the client's chest to count respirations accurately. The nurse documents that the client's respirations are shallow and rapid. The client's respiratory rate is 30 per minute. From this finding, the nurse is concerned the client is: 1. Anxious. 2. Normal. 3. Bored. 4. Fatigued. The nursing instructor is observing a student nurse assess the client's respiratory system. The student demonstrates proper technique for auscultation when moving the stethoscope: 1. From base to apices of lungs. 2. First down one side of the thorax, then down the other. 3. From side to side. 4. First up one side of the thorax, then up the other. A female client is hospitalized with injury and tissue destruction of the left pectoralis major and serratus anterior muscles due to a motor vehicle accident. The nurse would include which of the following information during the discharge teaching? 1.Physical therapy 2. Support bras 3. Prosthestic devices 4. Plastic surgery True or False: The tail of Spence, also called the axillary tail, is the portion of breast tissue that expends superiolaterally into the axilla. True The nurse is conducting a breast health workshop for a group of women. Which of the following would the nurse include in this workshop when outlining risk factors for breast cancer? (Select all that apply.) 1. Low socioeconomic status 2. Positive family history 3. Caucasian race 4. Female age 35 to 40 5. Hormone replacement therapy The nurse is teaching a group of high school males about self-breast examination. The nurse knows the teaching has been effective when one of the males makes which of the following comments regarding breast cancer in males? 1. "I need to be concerned only if I have pain in my chest." 2. "I'll be able to know about problems if I see changes in my chest." 3. "Breast cancer is not something I have to worry about." 4. "I know that I need to do monthly self-breast exams." The nurse is examining a client with a history of benign breast disease (sometimes referred to as fibrocystic breast disease). The nurse would expect which of the following findings during this assessment? (Select all that apply.) 1. Hard, fixed nodules 2. Freely movable masses 3. Straw-colored discharge from the nipples 4. Masses with well defined boundaries 5. Thickened breast tissue The nurse is assessing a client and confirms the presence of galactorrhea. The nurse understands that this finding is: 1. probably an infection. 2. suggestive of endocrine disorders. 3. usually indicative of lactation. 4. may indicate a malignancy A menopausal woman comes to the clinic with complaints of thin, watery nipple discharge with blood present. The nurse would suspect which of the following disorders in this client? 1. Mammary duct ectasia 2. Intraductal papillomas 3. Fibrocystic disease 4. Breast malignancy The nurse is performing an assessment on a newborn and notes a thin, milky discharge from the infant's nipple. The nurse knows this is a: 1. highly irregular finding. 2. common finding in newborns. nital anomaly. 4. reason to call in a specialist. The nurse working in a predominately Hispanic community outlines a breast health screening. The nurse is aware that: 1. Hispanic women have a higher incidence of breast cancer after age 40. 2. Breast cancer is the leading cause of cancer death in Hispanic women. 3. This cultural group is strict about performing monthly self breast exams. 4. Hispanic women have an open attitude about private issues. True or False: Hispanic women, along with Asian women, have the highest rates of breast cancer False. They have the lowest rates of breast cancer The nurse is preparing to perform a cardiac assessment on a client. Rank the following pieces of the assessment in order of occurrence. --Inspection of the client's head and neck, chest, abdomen, and extremities --Percussion of the client's chest --Auscultation of the client's heart, apical pulse, and carotid arteries --Palpation of the precordium and pulses Inspect, Palpate, Percuss, Auscultate The nurse is assessing a 20-year-old client and notes the presence of bilateral earlobe creases. The nurse would choose which of the following actions? (Select all that apply.) 1. Ask the client about any history of injuries to his ears. 2. Assess the client's risk factors for coronary artery disease. 3. Document this finding as normal. 4. Document the finding and notify the healthcare provider. 5. Refer the client to a plastic surgeon. The nurse is percussing the client's anterior chest and notes a dull sound over an area where lung tissue is normally found. Which of the following would the nurse associate with this finding? 1. This is a normal finding. 2. The client's heart may be enlarged. 3. The client has a pulse deficit. 4. The client has developed a murmur. The student nurse is assessing the client's cardiovascular system while the experienced nurse observes. The employment of which of the following techniques by the student nurse indicate the need for further education? (Select all that apply.) 1. The student nurse examines the client's legs and notes that the client's hair is evenly distributed. 2. The client complains of discomfort while lying flat. The student nurse auscultates the client's chest quickly while the client continues to lie flat. 3.The student nurse examines the client's hands and fingers and notes the presence of clubbing. 4. The student nurse gently palpates the client's carotid arteries simultaneously to determine pulse strength, rhythm, and rate. 5. The student nurse determines that the apical impulse is located at the fifth intercostal space at the midclavicular line. During the focused interview, the client makes the following statements. Which of the following statements indicates that the client has an increased risk of developing cardiovascular disease? 1. "My total cholesterol has always been around 170." 2. "I know my grandmother had diabetes, but every time it has been checked mine has been normal." 3. "I was diagnosed with hypothyroidism about 5 years ago." 4. "My doctor always tells me when I come in that my blood pressure is low." A client presents with an enlargement of several cervical lymph nodes and asks the nurse about the function of these structures. The nurse would respond with which of the following statements? 1. "They make lymphocytes for you." 2. "Your lymph nodes filter blood for your body." 3. "Your lymph nodes help to remove infectious organisms." 4. "They are responsible for the break down of old red blood cells." A 31-year-old female client wishes to begin taking oral contraceptives. The medical history indicates that the client had a deep vein thrombosis three years ago. After reviewing the objectives set forth in Healthy People 2020, which of the following is the best response by the nurse? 1. "You will also have to take blood thinners." 2. "We can have the healthcare provider write you a prescription today." 3. "Taking oral contraceptives increases your risk of developing clots." 4. "I need to perform a Homan's test on you." The nurse is documenting about an ulcer on the lateral aspect of the client's right great toe. The nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding. To help determine information about the origin of the client's ulcer, which of the following pieces of the assessment will be most useful for the nurse? 1. Homan's sign 2. Peripheral pulses 3. Skin turgor 4. Calf measurements While performing the assessment of the client's peripheral vascular system, the nurse notes that there was a rapid filling of superficial veins during the Trendelenburg test. These findings would be most consistent with which of the following disorders? 1. Valve incompetence 2. Arterial insufficiency 3. Phlebitis 4. Venous insufficiency A female client being examined by the nurse exhibits 2 pitting edema in the right arm, while the left arm is normal in size. Which of the following responses by the nurses is most important at this time? 1. "How much salt do you have in your diet?" 2. "Do you ever feel self-conscious about your arm?" 3. "Does the other arm swell also?" 4. "Tell me about your past surgical procedures." The nurse is completing discharge instructions for a client admitted with esophagitis. Which of the following statements by the client indicate that the client requires further education? (Select all that apply.) 1. "I told my wife to stop making serving me all of those vegetables." 2. "I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle." 3. "I can do all of this stuff you're talking about as long as I don't have to give up my beer." 4. "I'm going to talk to my doctor about a nicotine patch." 5. "The root of this problem is that I just sleep too much." The nurse is performing an abdominal assessment on a client. While the nurse is palpating the lower border of the liver, the nurse asks the client to take a deep breath and hold it. The client complains of a sharp pain located in the right upper quadrant. In which of the following ways would the nurse accurately document this finding? 1. Positive Murphy's sign 2. Positive Blumberg's sign 3. Presence of pain at McBurney's point 4. Positive Psoas sign True or False: Pain felt on sudden release of steadily applied pressure on a suspected area of the abdomen, indicative of peritonitis is a negative Blumberg's sign False. This is indicative of a POSITIVE Blumberg's sign (the pain felt on the sudden release is also referred to as rebound tenderness) True or False: McBurney's point is a point on the abdominal wall that lies between and right anterior superior iliac spine and is the point where the most pain is elicited by pressure in acute appendicitis True A client asks the nurse, "What's the purpose of a gall bladder anyway? My mom lived for many years without her gallbladder after she had to have it taken out." Which of the following information would be beneficial for the nurse to share with this client? 1. "It stores bile until it is needed for digestion of fats." 2. "You are right. We still don't know the function of the gallbladder." 3. "It helps you digest carbohydrates by producing enzymes." 4. "It destroys old red blood cells." The student nurse is preparing to examine a client who is complaining of left lower quadrant abdominal pain. The experienced nurse is observing the student nurse's abdominal assessment. Which of the following statements by the student nurse would indicate that the student nurse requires further education? (Select all that apply.) 1. "I am going to stand on your left side so I can feel your liver better." 2. "I'm going to place this drape over you so you don't feel too exposed during this examination." 3. "I am going to place this pillow behind your head and this pillow under your knees." 4. "I've been told you are experiencing some pain in the lower left area of your abdomen. I will examine that area first." 5. "It is a little cool in our examination room; may I turn up the thermostat?" The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the right upper portion of the back. The client states, "This has been happening more often after I eat rich, high-fat foods." The nurse would suspect which of the following? 1. Pancreatitis 2. Cholecystitis 3. Duodenal ulcer 4. Gastritis The nurse is performing an abdominal assessment on the client. Rank the following steps of assessment in the order that they should be performed: Percuss the abdomen, Palpate the abdomen, Visualize the quadrants of the abdomen, Auscultate the abdomen 1. Visualize the quadrants of the abdomen 2. Auscultate the abdomen 3. Percuss the abdomen 4. Palpate the abdomen The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. As the nurse inspected the client's abdomen, the nurse suspected that the client had developed ascites. The nurse would perform which of the following nursing interventions as a result of this finding? (Select all that apply.) 1. Measure the client's abdominal girth. 2. Obtain stool specimen for culture and sensitivity. 3. Bilateral leg measurements. 4. Percuss the abdomen at midline. 5. Obtain stool specimen for occult blood. The client was recently admitted to the hospital with left lower quadrant pain. The client states, "It feels like my belly is cramping." Guarding is noted during the abdominal examination. During the focused interview, the client admitted to experiencing a significant amount of occupational stress. The nurse reviews the information included in the chart above and determines that the client has developed a specific condition. What is likely going on with this patient? Hint: The client's white blood cell count, temperature, and blood pressure are elevated as a result of the infection. High-fiber food intake can be a precipitating factor. This client is most likely experiencing diverticulitis. The nurse is palpating the left upper quadrant of a client's abdomen. Which of the following organs may be assessed during this portion of the assessment? (Select all that apply.) 1. Spleen 2. Stomach 3. Appendix 4. Gallbladder 5. Liver 1. Spleen 2. Stomach The nurse is examining a male adolescent with suspected spermatic cord torsion. The nurse would anticipate which of the following as a priority intervention? 1. Prepare for surgery. 2. Elevate the scrotum. 3. Administer anti-inflammatory medications. 4. Medicate for pain with narcotics. The nurse has completed testicular self-exam teaching for a male client. Which of the following statements if made by the client would indicate the need for further instruction? 1. "I will feel hardened areas where the testicles and epididymis are located." 2. "I should be in a warm room or the shower to perform this exam." 3. "I should apply gentle pressure to each testicle to feel the area." 4. "I should perform this exam monthly." During the examination of an elderly male the nurse notes thin, gray pubic hairs and a scrotal sac that hangs significantly lower than the penis. The nurse would correctly choose which of the following actions? 1. Inform the client that he is no longer fertile. 2. Notify the healthcare provider of the findings. 3. Document the findings as normal. 4. Ask the client about his sexual practices. The parents of a 9-year-old boy voice concerns about the seemingly advanced level of sexual maturity of their son. The examination reveals the child has thick pubic hair and enlarged genitalia. Which treatment intervention may be anticipated by the nurse? 1. Continued observation of the rate of maturation for the next 6 to 9 months 2. Reduction of processed foods in the diet to reduce hormone exposure 3. Referral to an endocrinologist 4. Administration of estrogen to reduce the impact of escalating testosterone levels A male is being seen at the urologist office with concerns relating to his fertility. Which of the following factors may warrant further investigation? 1. The client's medical history indicates a past history of marijuana use. 2. The client works in a paint manufacturing company. 3. The client was treated for gonorrhea 2 years ago. 4. The client has a history of genital herpes simplex. The nurse notes reddened areas on the labia and a discharge that is white and curd-like in the vaginal canal when examining a female client. The nurse would suspect which of the following conditions in this situation. 1. Herpes infection 2. Yeast infection 3. Venereal warts 4. Contact dermatitis True or False: The Bartholin's glands, or greater vestibular glands, are located posteriorly at the base of the vestibule and produce mucus, which is released into the vestibule. True The nurse is examining the external genitalia of a female client and notes raised, cauliflower-shaped papules. The nurse would suspect which of the following conditions in this situation? 1. Genital warts 2. Herpes infection 3. Contact dermatitis 4. Bartholin's abscess The nurse is providing education on menopause to a group of female clients. Which of the following statements made by one of the clients would indicate the need for further instruction by the nurse? 1. "Vaginal dryness may occur during menopause." 2. "My mood changes are a normal part of menopause." 3. "Night sweats and hot flashes are commonly experienced." 4. "My periods may be irregular and less frequent." The nurse is performing a vaginal examination on a client who has had a hysterectomy. Which of the following would the nurse choose to do in this situation? 1. Use the surgical stump for the cervical scrape. 2. Defer the cervical scrape. 3. Tell the client an examination is not needed. 4. Use the vaginal wall for the cervical scrape. The nurse notes swelling and tenderness of the olecranon process during palpation. The client's chief complaint is pain upon movement of the forearm and wrist. The nurse would correctly suspect which of the following conditions in this situation? 1. Epicondylitis 2. Arthritis 3. Bursitis (painful, inflamed warm area) 4. Crepitus The student nurse is assessing the client's lateral flexion. Which of the following instructions by the student to the client indicates the need for further instruction? (Select all that apply.) 1. "Touch your chin to your chest." 2. "Attempt to rotate your head in a circular manner." 3. "Attempt to raise your shoulders up toward your ears." 4. "Tilt your head back and look at the ceiling." 5. "Lean your head to the side and attempt to touch your ear to your shoulder." 1. "Touch your chin to your chest." (flexion but not lateral) 2. "Attempt to rotate your head in a circular manner." (flexibility and mobility) 3. "Attempt to raise your shoulders up toward your ears." (flexibility) 4. "Tilt your head back and look at the ceiling." (hyperflexion) The nurse is examining a client with a chief complaint of pain in the right great toe. The nurse notes hardened nodules on the lateral aspect of the toe, as well as redness and swelling. The nurse would suspect which of the following? 1. Synovitis 2. Bunion 3. Hammertoe 4. Gout 4. Gout The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout The nurse notes full range of motion against gravity with moderate resistance when assessing muscle strength of the upper extremities in a client. The nurse would correctly document which of the following choices? 1. Good 2. Poor 3. Fair 4. Normal 1. Good (aka a rating of 4) The nurse is planning a program to promote Healthy People 2020 focus areas relating to osteoporosis. Which of the following would appropriately serve as a primary prevention program? 1. The development of community support programs for individuals who have been diagnosed with osteoporosis. 2. The development of a program to address available medication therapies for the individual with osteoporosis. 3. Community screening programs to identify individuals who have early onset osteoporosis. 4. Community education programs to discuss methods that can be implemented to reduce the chance of developing osteoporosis. The client's chief complaint is inability to move the fourth and fifth fingers during the nurse's interview. The nurse notes severe flexion in both of the affected fingers and upon palpation, but there are no complaints of pain from the client. The nurse would suspect which of the following conditions in this situation? 1. Carpal tunnel syndrome 2. Osteoarthritis 3. Dupuytren's contracture 4. Bursitis A young adult is seen in the clinic complaining of a lump the left wrist, but states it is not painful. The nurse notes a round mass on the back of the wrist. The nurse would suspect which of the following? 1. Carpal tunnel syndrome 2. Rheumatoid arthritis 3. Ganglion 4. Osteoarthritis 3. Ganglion Round, fluid-filled masses The nurse is admitting a client with a shoulder dislocation. The client tells the nurse that the healthcare provider has told her she has a dislocated shoulder. The client asks the nurse what this diagnosis means. The nurse would respond with which of the following statements? 1. "I cannot tell you without your healthcare provider's permission." 2. "Your shoulder is fractured and separated from the joint." 3. "You have a muscle tear at the shoulder." 4. "Your shoulder bone has come apart from the shoulder joint." The client's chief complaint is pain in the foot. The nurse notes a deviation of the great toe from the midline and crowding of the remaining toes. There is enlargement and inflammation noted in the area. The nurse would suspect which of the following conditions in this situation? 1. Bunion 2. Gouty arthritis 3. Hammertoe 4. Flat foot 1. Bunion aka hallux valgus The nurse is assessing a client that experienced a head injury and assigns a Glascow Coma Scale rating of 3. The nurse would correctly note which of the following for this client? (Select all that apply.) 1. Pupils fixed and dilated 2. Pupil response sluggish 3. No motor movement 4. No verbal response 5. No response with eyes with commands True or False: The sense of smell is assessed when the vestibulocochlear (cranial nerve VIII) is being evaluated. FALSE. The sense of smell is assessed when the OLFACTORY NERVE (cranial nerve I) is being evaluated. The nurse is preparing a neurological health seminar for the staff on the unit. Which of the following statements would the nurse include in the teaching plan? 1. Alcohol or drug use increases the risk for accidents and injury. 2. Older adults experience fewer accidents and injuries. 3. Head injuries are more common in adults than children. 4. Epilepsy occurs only in children under age 15. The nurse is caring for a client with a traumatic brain injury. The client has begun to experience bradycardia. What area of the brain is likely responsible for the changes in heart rate? The brain stem is responsible for control of the vital signs. The nurse is reviewing the history and physical on a client and notes a history of syncope. The nurse would implement which of the following for this client? 1. Seizure precautions 2. Soft diet 3. Intake and output 4. Fall precautions The student nurse has performed a rapid assessment on the diabetic client and is reporting information back to the experienced nurse. The student nurse notes that the client is experiencing emotional stress following his wife's recent death. Which of the following statements by the nurse student nurse regarding the effects of emotional stress indicate the need for further education? 1. "He may be hyperglycemic." 2. "Emotional stress can negatively impact his immune system's ability to function." 3. "I should not ask about his use of drugs or alcohol at this time." 4. "He's probably not been eating well recently." The nurse is preparing to assess the general appearance of the hospitalized client. Which of the following statements by the client are expected if the client is experiencing undernutrition (Select all that apply.) 1. "I know my blood pressure has been up because I've been experiencing headaches in the morning, just like last time." 2. "My nails are so brittle." 3. "It seems like I get catch every bug that comes along. I can't seem to stay well." 4. "I have gained 5 pounds over the last week and my ankles and feet are swollen." 5. "This wound that I've had for the last 3 months on my leg won't heal." The nurse is performing an initial assessment on the hospitalized client. The nurse is assessing the client's respiratory system. Rank the following steps in the correct sequence: The nurse warms his stethoscope and listens to the client's lung sounds in each lung field, The nurse gently palpates the client's thorax, The nurse unties the client's gown to better visualize the client's thorax, The nurse percusses the client's thorax 1. The nurse unties the client's gown to better visualize the client's thorax 2. The nurse gently palpates the client's thorax 3. The nurse percusses the client's thorax 4. The nurse warms his stethoscope and listens to the client's lung sounds in each lung field The client is comatose and the healthcare provider orders that the client's temperature is to be taken by the rectal route. The student nurse is assisting the more experienced nurse and volunteers to obtain the client's temperature. Which of the following statements by the student nurse indicate the need for further education? 1. "This is an appropriate way to monitor a client's temperature if they are unable to close the mouth around the oral thermometer." 2. "The probe for a rectal thermometer is usually red." 3. "I will need to turn the client into the prone position." 4. "I should insert the thermometer 1.5 to 4 centimeters into the client's anus." The nurse is performing an assessment of the hospitalized client. After speaking with the client, the nurse believes that the client is demonstrating altered thought processes. Which of the following statements by the client validate the nurse's conclusion? (Select all that apply.) 1. "My doctor has only been to visit me once during the last three days. I'm starting to feel angry that she hasn't come to see if I'm doing better." 2. "I have never had so much pain. I just don't feel like speaking with you right now." 3. "Red squirrels dance on the divine divide." 4. "When I was little I had 4 cats. Can I wear a dress instead of this hospital gown?" 5. "I wish that my grandmother's daughter would visit me more often." MUSCLE STRENGTH GRADING Grade the following from 0-5: No contraction Slight contraction, no movement Full range of motion without gravity Full range of motion with gravity Full range of motion, some resistance Full range of motion, full resistance