1. During assessment of the lower extremities of a male client the nurse is unable to
palpate the dorsalis pedis pulse. What action should the nurse take first?
a. Notify the Physician
b. Return in a few hours and reassess
c. Ask the client if this is "normal" for him
d. Reposition the fingers and assess again < Ans > C. Ask the Client if this is normal
2. An example of objective data obtained during the physical assessment includes:
Select all that apply
a.Sore throat
b.Audible wheeze
c.Headache
d.Tinnitus
e.Pressure ulcer rt. ankle < Ans > b.Audible wheeze
e.Pressure ulcer rt. ankle
3. A mother is at the clinic with her 2-year-old son and states "he won't go to sleep at
night & during the day he has several fits. I get so upset when this happens."
The nurse's best verbal response should be < Ans >
a."Go on, I'm listening
b."Tell me what you mean by fits."
c."Yes, it can be upsetting when a child has a fit."
d."Don't be upset when he has a fit, all 2-year-olds have fits < Ans > b."Tell me what you
,mean by fits."
4. Which of the following statements illustrates the use of open-ended ques- tions?
Select all that apply
a.Elicits cold facts
b.Builds & enhances rapport
c.Leaves interactions neutral
d.Calls for short one-to two-word answers
e.Used when narrative information is needed < Ans > b.Builds & enhances
rapport e.Used when narrative information is needed
, 5. A client's reason for seeking care is "shortness of breath". When obtaining a health
history, which of these questions, by the nurse, would obtain the most helpful
information?
a.Will you please describe the activities that cause you to be short of breath?
b.Have you been short of breath for long?
c.Hon, are you short of breath now?
d.Do you have interstitial pneumonia? < Ans > a. Will you please describe the activities
that cause you to be short of breath?
6. During an exam the nurse notices the client has round, flat red lesions on the skin
of the forearm. The nurse suspects < Ans >
a.Petechiae
b.Pruritis
c.Herpes zoster
d.Psoriasis < Ans > a. Petechiae
7. A 65-year-old man with emphysema has come to the clinic for a follow-up appt.
On assessment of the skin, the nurse might expect to assess the follow- ing < Ans >
a.Jaundice
b.Senile angiomas
c.Herpes zoster
d.Clubbing of the nails < Ans > d. Clubbing of the nails
8. A mother presents with her son, who has been in a new day care facility. On
examination the nurse assesses moist, thin vesicles with an erythematous base around
the nose and mouth. The nurse suspects < Ans >