TEST BANK for Health and Physical Assessment in Nursing 2nd Edition. (Complete Download)

Health and Physical Assessment In Nursing 2nd Edition DAmico Test Bank Health and Physical Assessment In Nursing 3rd Edition DAmico Test Bank Chapter 1 Question 1 Type: MCSA The nurse is obtaining a health history from a client who reports that he is healthy and has no health concerns. As part of the health history, the nurse documents that the client reported that he has high blood pressure and suffers from a leg ulcer that remains unhealed after 6 months. Which of the following statements would be the best choice for the nurse to use at this point in the interview? 1. “I feel that you may be in denial about your health status.” 2. “Tell me about your definition of being healthy.” 3. “Do you understand what hypertension is?” 4. “Is there anything else you are not telling me?” Correct Answer: 2 Rationale 1: More information would be needed before the nurse could attribute the client’s viewpoint as denial or lack of knowledge. Rationale 2: A client will have his or her own definition of health, illness, and wellness. The individual’s concept of health and wellness is influenced by many factors, including age, gender, race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and self-expectations. Rationale 3: The client’s history of hypertension is a valid area requiring further investigation but the nurse must first ascertain the client’s definition of healthy. Rationale 4: There is not enough information to determine the client’s withholding of information to the nurse. Global Rationale: A client will have his or her own definition of health, illness, and wellness. The individual’s concept of health and wellness is influenced by many factors, including age, gender, race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and self-expectations. More information would be needed before the nurse could attribute the client’s viewpoint as denial or lack of knowledge. The client’s history of hypertension is a valid area requiring further investigation but the nurse must first ascertain the client’s definition of healthy. There is also not enough information to determine the client’s withholding of information to the nurse. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Identify the factors to consider in health assessment

Question 2 Type: MCSA The nurse is documenting in the client’s medical record and wishes to use SOAP charting. The nurse includes which of the following under the assessment category? 1. The client’s blood pressure was 177/93. 2. The recent loss of employment and insurance have prevented the client from being able to afford prescription medications. 3. The client reports having lost her job and insurance 3 months ago. 4. Referrals have been made to social services to determine financial assistance programs available. Correct Answer: 2 Rationale 1: This is the “O” component, objective data. Rationale 2: The “A” component of the SOAP note refers to conclusions drawn from the subjective and objective data obtained. Rationale 3: This is subjective data. Rationale 4: This is the “P” component, plan. Global Rationale: The “A” component of the SOAP note refers to conclusions drawn from the subjective and objective data obtained. The client’s recent loss of employment and the potential that this was a contributing factor in the inability to afford medications is an example of a conclusion. The client’s reported blood pressure would be an example of objective data. Objective data is information that can be measured by the examiner. Blood pressure is not an example of subjective information nor is it a conclusion. The client’s reported loss of employment and insurance is an example of subjective data. The statement does not include conclusions as to the results of these events. Making referrals to social services is an example of an intervention. It is not a conclusion. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Identify the factors to consider in health assessment. Question 3 Type: MCSA The nurse is presenting a workshop on wellness and health promotion and the initiatives of Healthy People 2020 as a resource for this topic. After the session, which of the following statements by a participant indicates an understanding concerning the initiatives proposed? 1. “It will allow health care providers to lobby legislators for more funding.”

2. “The primary goal of Healthy People 2020 is to assist health care providers in determining risk factors for premature birth.” 3. “Healthy People 2020 seeks to promotes health, prevent illness, disability, and premature death.” 4. “The initiatives will outline standards of care for providers in managing diseases.” Correct Answer: 3 Rationale 1: Health care providers and other persons interested in programs to promote health have found the document to be a useful source of information in their efforts to gain funding. Rationale 2: The Healthy People 2020 initiative is a 10-year strategy intended to promote health, prevent illness, disability, and premature death. The document identifies leading health indicators that reflect public health concerns. Risk factors for premature birth may be part of those health indicators, but the scope of the document covers broad areas of concern. Rationale 3: The Healthy People 2020 initiative is a 10-year strategy intended to promote health, prevent illness, disability, and premature death. Rationale 4: Standards of care in disease management is not a component of the document. Global Rationale: The Healthy People 2020 initiative is a 10-year strategy intended to promote health, prevent illness, disability, and premature death. The document identifies leading health indicators that reflect public health concerns. Risk factors for premature birth may be part of those health indicators, but the scope of the document covers broad areas of concern. Health care providers and other persons interested in programs to promote health have found the document to be a useful source of information in their efforts to gain funding. Standards of care in disease management is not a component of the document. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.2: Discuss the importance of Healthy People 2020 and its relevance to health assessment. Question 4 Type: MCSA The nurse is developing a handout for clients in a healthcare provider’s office. The nurse would include which of the following focus areas in this handout to emphasize current changes in the health care delivery system? 1. Class recommendations for diabetics concerning insulin administration A2.Guidelines from the Centers for Disease Control outlining plans to manage outbreaks of disease, eradicating the use of toxins 2. Guidelines from the Centers for Disease Control outlining plans to manage outbreaks of disease, eradicating the use of toxins 3. Resources available to treat chronic pain

4. Class listings for exercise classes available in the community Correct Answer: 4 Rationale 1: Symptom management, illness care, and pain management are addressed by the health care delivery system but are not the primary focus, as clients are taking a more active role in managing their own care. Rationale 2: Management of outbreaks of disease is a function of governmental organizations and health care providers in the community, but is not a focus of individual care. Rationale 3: Symptom management, illness care, and pain management are addressed by the health care delivery system but are not the primary focus, as clients are taking a more active role in managing their own care. Rationale 4: The focus of health care in the United States today is wellness, prevention of disease, health promotion and health maintenance, for which a listing of exercise classes is appropriate. Global Rationale: The focus of health care in the United States today is wellness, prevention of disease, health promotion, and health maintenance, for which a listing of exercise classes is appropriate. Symptom management, illness care, and pain management are addressed by the health care delivery system but are not the primary focus, as clients are taking a more active role in managing their own care. Management of outbreaks of disease is a function of governmental organizations and health care providers in the community, but is not a focus of individual care. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.8: Discuss the elements of a teaching plan. Question 5 Type: MCSA The nurse is admitting a client to the acute care facility. The health history form has a place for recording subjective data. The nurse understands that primary subjective data should be obtained from which of the following sources? 1. The client’s physical assessment 2. The client’s self-reports 3. The client’s healthcare provider 4. The client’s significant other Correct Answer: 2 Rationale 1: The physical assessment will be recorded as objective data.

Rationale 2: Subjective data are gathered from the interview. The interview includes the health history and focused interview. Data will come from primary and secondary sources. Rationale 3: The client’s healthcare provider and significant other may contribute in the data collection process. The information obtained from friends and family members is considered subjective. This source of information is termed secondary. Rationale 4: The client’s significant other may contribute in the data collection process but that input is classified as subjective. Global Rationale: Subjective data are gathered from the interview. The interview includes the health history and focused interview. Data will come from primary and secondary sources. The client is considered the primary source of subjective information. Family members and healthcare providers are examples of secondary sources of subjective information. The physical assessment will be recorded as objective data. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.7: Describe the role of the professional nurse in health assessment. Question 6 Type: MCSA The nurse is reviewing a client’s medical records and notes various forms of information. The nurse understands that which of the following are subjective data? 1. The client states, “My abdomen hurts on the left side after eating.” 2. The nurse notes the client’s abdomen is tender on the left side during palpation. 3. The CAT scan reveals a large mass in the left lower quadrant of the abdomen. 4. The client’s hemoglobin is 14.1 gm/dL. Correct Answer: 1 Rationale 1: Subjective reports by the client are those feelings or symptoms that cannot be observed by others, of which “My abdomen hurts” is an example. Rationale 2: Physical examination findings, laboratory analysis reports and radiographic findings are objective data. Rationale 3: Physical examination findings, laboratory analysis reports and radiographic findings are objective data. Rationale 4: Physical examination findings, laboratory analysis reports and radiographic findings are objective data.

Global Rationale: Subjective reports by the client are those feelings or symptoms that cannot be observed by others. Objective reports are those factors that are based upon observations of others. Physical examination findings, laboratory analysis reports, and radiographic findings are objective data. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Identify the factors to consider in health assessment. Question 7 Type: MCSA The nurse is reviewing a client’s medical records and notes various information. The nurse understands that which of the following is an example of objective data? 1. “I hurt my head.” 2. “I am 6 years old and I’m here because I fell.” 3. “Six-year-old Hispanic female sitting on examination table holding a towel to her forehead.” 4. “Client states that she fell at the playground.” Correct Answer: 3 Rationale 1: Statements the client makes are subjective data. Rationale 2: Statements the client makes are subjective data. Rationale 3: Objective data are data that can be observed or measured by the nurse. The nurse can see the child holding the towel to her head and can use her birth date to determine her age. Rationale 4: Statements the client makes are subjective data. Global Rationale: Objective data are data that can be observed or measured by the nurse. The nurse can see the child holding the towel to her head and can use her birth date to determine her age. Statements the client makes are subjective data. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Identify the factors to consider in health assessment. Question 8 Type: MCSA

The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. What should the nurse do next in this situation? 1. Report the lack of achievement of the goals to the healthcare provider. 2. Review the data and modify the plan. 3. Reformulate the nursing diagnosis to a more realistic one. 4. Request a consult for the client to be seen by a pulmonologist. Correct Answer: 2 Rationale 1: Reporting the lack of achievement of the goals to the healthcare provider is not appropriate, though reporting undesirable client physiologic responses may be. Rationale 2: The plan of care should be evaluated periodically, at the established time frames, to determine achievement of the goals. If goals are not achieved, then the data need to be further assessed and the plan modified. Rationale 3: Reformulating the nursing diagnosis to a more realistic one is not the best course of action as the diagnosis established came from subjective and objective data specific to that diagnosis. Rationale 4: There are no data to support the need for additional medical consultations. Global Rationale: The plan of care should be evaluated periodically, at the established time frames, to determine achievement of the goals. If goals are not achieved, then the data need to be further assessed and the plan modified. Reporting the lack of achievement of the goals to the healthcare provider is not appropriate, though reporting undesirable client physiologic responses may be. Reformulating the nursing diagnosis to a more realistic one is not the best course of action as the diagnosis established came from subjective and objective data specific to that diagnosis. There are no data to support the need for additional medical consultations. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.5: Define the steps of the nursing process. Question 9 Type: MCSA The community health nurse is preparing to conduct a program for a group of nursing students concerning health and wellness. Which of the following statements by a participant indicates the most comprehensive and accurate understanding of health? 1. “Health is the absence of illness, disease, and symptoms.” 2. “Health is a state of well-being and the use of every power the person possesses to the fullest extent.”

3. “Health is the state when a person is viewed as a holistic being.” 4. “Health is a state of complete physical, mental, and social well-being.” Correct Answer: 4 Rationale 1: Health is much more than the absence of illness and disease. Rationale 2: Defining health as a state of well-being is limiting as it does not encompass the elements of an individual’s being such as physical, mental, and social. Rationale 3: While health does require a holistic approach, this definition does not explore the elements with the same clarity of the correct answer. Rationale 4: Health is defined as a state of complete physical, mental, and social well-being (WHO, 1947). Global Rationale: Health is defined as a state of complete physical, mental, and social well-being (WHO, 1947). Health is much more than the absence of illness and disease. Defining health as a state of well-being is limiting as it does not encompass the elements of an individual’s being such as physical, mental, and social. While health does require a holistic approach, this definition does not explore the elements with the same clarity of the correct answer. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.1: Discuss the various definitions of health. Question 10 Type: MCSA The nurse is caring for a client who is recovering from abdominal surgery. When determining the best goal statement for the client concerning level of pain, which of the following is most appropriate? 1. The client will verbalize pain relief using an intensity rating in 4 hours. 2. The client will state that he feels fine in 4 hours. 3. The nurse will observe fewer signs of pain in the client’s demeanor. 4. The nurse will reevaluate the client’s pain level every 2 hours. Correct Answer: 1 Rationale 1: The goal statement is directly related to the nursing diagnosis. Goal statements are stated in a positive fashion, and have measurable criteria. Rationale 2: This statement is not related directly related to the diagnosis and is not measurable.

Rationale 3: A goal statement must be reflective of client activities. This is an incorrect answer because it reflects activities of the nurse and not the client. Rationale 4: A goal statement must be reflective of the client’s activities. This is an incorrect answer because it reflects activities of the nurse and is not client directed. Although there is a time frame listed it is not correct as it is related to nursing actions. Global Rationale: The goal statement is directly related to the nursing diagnosis. Goal statements are stated in a positive fashion, and have measurable criteria. Verbalization of the client of pain relief using a rating scale within a specified time period is an appropriately formatted, measurable statement. Statements by the client indicating he is feeling fine is not reflective of a measurable criteria. Statements indicating actions by the nurse are not correctly formatted goals for the client. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.5: Define the steps of the nursing process. Question 11 Type: MCSA The nurse is developing the plan of care for a client who is recovering from abdominal surgery. When planning interventions the nurse recognizes which of the following will best meet the needs of the client experiencing pain? 1. The healthcare provider will prescribe additional analgesics. 2. The client will have reduced pain after administration of analgesics. 3. The client will vocalize reduced levels of pain within 3 hours. 4. Assist the client with guided imagery to manage pain levels. Correct Answer: 4 Rationale 1: The prescribing of additional analgesics does not determine the characteristics of the pain and does not offer patient-driven information. Rationale 2: This is a goal statement, not an intervention. Rationale 3: This is a goal statement, not an intervention. Rationale 4: Nursing interventions, such as assisting the client with guided imagery, are geared to assist in meeting client goals. The interventions are derived from the second part of the diagnosis, which is the etiology. The defining characteristics provide the background support for the diagnosis. The diagnostic label is global and requires specification before attempting to determine a goal. The client’s stated wishes are an important component of planning, and may be included in the list of interventions as appropriate. The interventions are based upon nursing actions.

Global Rationale: Nursing interventions are geared to assist in meeting client goals. The interventions are derived from the second part of the diagnosis, which is the etiology. The defining characteristics provide the background support for the diagnosis. The diagnostic label is global and requires specification before attempting to determine a goal. The client’s stated wishes are an important component of planning, and may be included in the list of interventions as appropriate. The interventions are based upon nursing actions. The prescribing of additional analgesics does not determine the characteristics of the pain and does not offer patient driven information. The reduction of pain and vocalization of pain levels within 3 hours are goal statements, not interventions. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.6: Describe the critical thinking process with relevance to health assessment. Question 12 Type: MCSA The nursing instructor is discussing Healthy People 2020 with a group of nursing students. One of the students questions the instructor how this work will impact hospitalization. The best response by the nursing instructor would be: 1. “Healthy People 2020 is a tool for the healthcare providers to offer information to their clients.” 2. “Healthy People 2020 seeks to improve health and prevent illness, disability, and premature death.” 3. “The purpose of Healthy People 2020 is to reduce health care costs for hospitalized clients.” 4. “Healthy People 2020 is seen as a tool by hospitals to reduce length of stay.” Correct Answer: 2 Rationale 1: Healthy People 2020 is a resource tool for all health care professionals but its purpose is not to provide patient education between the healthcare provider and client. Rationale 2: Healthy People 2020 presents a 10-year strategy with objectives intended to enhance health and prevent illness, disability, and premature death. Rationale 3: Reduction of hospital costs is the not the primary purpose of Healthy People 2020. Rationale 4: Reduction of length of stay is the not the primary purpose of Healthy People 2020. Global Rationale: Healthy People 2020 presents a 10-year strategy with objectives intended to enhance health and prevent illness, disability, and premature death. Healthy People 2020 is a resource tool for all health care professionals but its purpose is not to provide patient education between the healthcare provider and client. Reduction of hospital costs is the not the primary purpose of Healthy People 2020. Cognitive Level: Applying

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.2: Discuss the importance of Healthy People 2020. Question 13 Type: MCSA The recent graduate nurse is orienting to the medical surgical care unit. The graduate nurse has prepared a nursing care plan for a client admitted for exacerbation of ulcerative colitis. The goal statement is, “The client will resume normal bowel elimination patterns.” The graduate nurse has asked the charge nurse to review the care plan. What action by the charge nurse is indicated? 1. Express to the new nurse that the goal statement meets criteria. 2. Explain to the new nurse that the lack of time frame makes the goal inappropriate. 3. Express to the new nurse that the goal statement is not reflective of the client’s admitting diagnosis. 4. Accept the care plan for inclusion into the client’s medical record as it is accurate. Correct Answer: 2 Rationale 1: This goal statement does not meet criteria as it lacks a time frame. Rationale 2: Time frames are an important component of goal statements and provide guidelines for when to evaluate the achievement of the goal. Rationale 3: The defining characteristics of the diagnosis and the etiology of the diagnosis are components of the diagnostic statement. Rationale 4: This goal statement does not meet criteria as it lacks a time frame. Global Rationale: This goal statement does not meet criteria as it lacks a time frame. Time frames are an important component of goal statements and provide guidelines for when to evaluate the achievement of the goal. The defining characteristics of the diagnosis and the etiology of the diagnosis are components of the diagnostic statement. The nurse’s role in achieving the goal is not a component of the goal statement. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.5: Define the steps of the nursing process. Question 14 Type: MCMA

The nurse is caring for a newly admitted client with Methicillin-resistant Staphylococcus Aureus (MRSA). Which of the following are appropriate goals of the initial health assessment? Standard Text: Select all that apply. 1. Determine the client’s current state of health and ongoing health-promotion activities. 2. Predict risks to current health status. 3. Use only objective data to determine client allergies. 4. Determine how frequently the client is able to change positions. 5. Identify health-promoting activities. Correct Answer: 1,5 Rationale 1: Determine the client’s current state of health and ongoing health-promotion activities: Health assessment goals are to determine the client’s current state of health and ongoing health-promotion activities. Rationale 2: Predict risks to current health status: Health assessment activities are used to predict risks to health, and identify health status both current and future. This includes physical, social, cultural, environmental, and emotional factors including wellness behaviors, illness signs and symptoms, client strengths and weaknesses, and risk factors. Rationale 3: Use only objective data to determine client allergies. The initial health assessment includes both objective and subjective information. Rationale 4: Determine how frequently the client is able to change positions. The initial health assessment includes both objective and subjective information and seeks to determine the potential an individual has to implement health-promoting activities. Health assessment activities are used to predict risks to health, and identify health status. This includes physical, social, cultural, environmental, and emotional factors including wellness behaviors, illness signs and symptoms, client strengths and weaknesses, and risk factors. The ability of the client to change positions is not a part of the initial health assessment. . Rationale 5: Identify health-promoting activities. The health assessment seeks to determine the potential an individual has to implement health-promoting activities. Global Rationale: Health assessment goals are to determine the client’s current state of health and ongoing health-promotion activities. The initial health assessment includes both objective and subjective information and seeks to determine the potential an individual has to implement health-promoting activities. Health assessment activities are used to predict risks to health, and identify health status. This includes physical, social, cultural, environmental, and emotional factors including wellness behaviors, illness signs and symptoms, client strengths and weaknesses, and risk factors. The initial health assessment does not include using objective data to determine client allergies and is not part of the initial health assessment. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Define the steps of the nursing process. Question 15 Type: MCSA While the nurse assesses a client who is hospitalized for an acute exacerbation of chronic obstructive pulmonary disease (COPD), the client becomes very short of breath. The nurse recognizes the need to stop the assessment to initiate respiratory support interventions. This is an example of which phase of critical thinking? 1. Collection of information 2. Evaluation 3. Generation of alternatives 4. Analysis of the situation Correct Answer: 4 Rationale 1: Collection of information is the initial step in the process. During this phase the nurse will assess available information. Rationale 2: Evaluation is the final step in the process. During evaluation the nurse will determine the effectiveness of actions taken. Rationale 3: When generating alternatives for action the nurse will use critical thinking skills to determine available options for action. Rationale 4: The nurse in the scenario will need to employ assessment skills to review and analyze the situation. The analysis will provide the nurse with the understanding of what the best plan of action will be. Global Rationale: The nurse in the scenario will need to employ assessment skills to review and analyze the situation. The analysis will provide the nurse with the understanding of what the best plan of action will be. Collection of information is the initial step in the process. During this phase the nurse will assess available information. Evaluation is the final step in the process. During evaluation the nurse will determine the effectiveness of actions taken. When generating alternatives for action the nurse will use critical thinking skills to determine available options for action. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.6: Describe the critical thinking process with relevance to health assessment. Question 16 Type: MCMA

The nurse is completing an admission assessment. The assessment form allows for the separation of subjective and objective data. Distinguish which of the following are examples of subjective data utilized by the nurse. Standard Text: Select all that apply. 1. The client’s mother informs the nurse that her daughter has not been sleeping due to pain. 2. The client states, “I have pain in my belly that is 7 out of 10.” 3. Abdominal assessment reveals a firm, hard abdomen. 4. The client is weak and looks very pale. 5. The client appears nervous during the data collection period. Correct Answer: 1,2 Rationale 1: The client’s mother informs the nurse that her daughter has not been sleeping due to pain. Subjective data is information the client experiences and communicates to the nurse. This information can be provided by either the client or other individuals. Rationale 2: The client states, “I have pain in my belly that is 7 out of 10.” Subjective data is information the client experiences and communicates to the nurse. Rationale 3: Abdominal assessment reveals a firm, hard abdomen. Data that are observed by the examiner are termed objective data. Rationale 4: The client is weak and looks very pale. Data that are observed by the examiner are termed objective data. Rationale 5: The client appears nervous during the data collection period. Data that are observed by the examiner are termed objective data. Global Rationale: Subjective data is information the client experiences and communicates to the nurse. This information can be provided by either the client or other individuals. Primary subjective data is information the client experiences and communicates to the nurse. Information provided by family is also considered subjective but is termed secondary. Assessment data that are observed by the examiner are termed objective data. Reports by the client’s mother are considered secondary subjective information. The statements made by the client are referred to as primary subjective data. The characteristics of the abdomen, the client’s strength level, color, and psychosocial assessment are termed objective data. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Identify the factors to consider in health assessment. Question 17

Type: MCSA A client with hepatitis B is admitted to the hospital. When obtaining the physical assessment, what should the nurse keep in mind regarding client confidentiality? 1. Confidentiality means that information sharing is limited to those directly involved in the client care. 2. Complete client confidentiality means that all members of the health care team may have access to the chart. 3. Health Insurance Portability and Accountability Act (HIPAA) helps to maintain client confidentiality and dictates who is to be communicating with the client. 4. The medical records are open to any hospital employee, including administration. Correct Answer: 1 Rationale 1: Confidentiality means that information sharing is limited to those directly involved in the client care. Rationale 2: Not all members of the health care team have access to the chart, only those who are directly caring for the client. Rationale 3: The Health Insurance Portability and Accountability Act (HIPAA) does not dictate who is allowed to communicate with the client. Rationale 4: The medical records are open to any hospital employee, including administration. Global Rationale: Confidentiality means that information sharing is limited to those directly involved in the client care. Not all members of the health care team have access to the chart, only those who are directly caring for the client. The Health Insurance Portability and Accountability Act (HIPAA) does not dictate who is allowed to communicate with the client. Hospital records are open only to those directly related to the care of the client. Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.7 Describe the role of the professional nurse in health assessment. Question 18 Type: MCSA The charge nurse is discussing with the new graduate nurse the care planning process for clients admitted to the unit. The graduate nurse correctly identifies the order of the steps of the nursing process as: 1. Diagnosis, Assessment, Planning, Implementation, Evaluation 2. Assessment, Diagnosis, Planning, Implementation, Evaluation 3. Planning, Assessment, Diagnosis, Implementation, Evaluation

4. Assessment, Planning, Diagnosis, Implementation, Evaluation Correct Answer: 2 Rationale 1: The nursing process is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client. The assessment phase, step 1, involves the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is planning. Implementation is step 4. The final stage in the process, step 5, is evaluation. Rationale 2: The nursing process is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client. The assessment phase, step 1, involves the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is planning. Implementation is step 4. The final stage in the process, step 5, is evaluation. Rationale 3: The nursing process is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client. The assessment phase, step 1, involves the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is planning. Implementation is step 4. The final stage in the process, step 5, is evaluation. Rationale 4: The nursing process is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client. The assessment phase, step 1, involves the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is planning. Implementation is step 4. The final stage in the process, step 5, is evaluation. Global Rationale: The nursing process is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client. The assessment phase, step 1, involves the collection of data. Step 2 of the nursing process is diagnosis. The nurse uses critical thinking and applies knowledge from the sciences and other disciplines to analyze and synthesize the data. Similar data is clustered together and become the basis for the nursing diagnosis. Step 3 of the process is planning. During the planning phase the nurse sets the course for the care to be delivered. Implementation is the fourth step. During the implementation phase, step 4, the care is delivered. The final stage in the process, step 5, is evaluation. The professional nurse compares the present client status to achievement of the stated goals or outcomes. At this time the nurse will need to modify the nursing care plan. Cognitive Level: Remembering Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.6: Define the steps of the nursing process. Question 19 Type: MCSA A client is hospitalized with end stage liver failure secondary to many years of alcoholism. The nurse begins collection of information by first: 1. Organizing how to proceed with the client and generating alternatives to the approach.

2. Identifying assumptions that can misguide or misdirect the assessment and intervention process. 3. Collecting information and determining its relevance as far as impacting the client care. 4. Identifying any inconsistencies in the communication from the client and or significant others. Correct Answer: 2 Rationale 1: Organizing how to proceed with the client occurs after identification of assumptions. Rationale 2: The process of data collection involves a systematic approach. The first step in the process involves the identification of assumptions. Assumptions may misguide or misdirect the process of assessment and intervention. Rationale 3: Collecting information and determining its relevance occurs after identification of assumptions. Rationale 4: Identifying any inconsistencies in communication occurs after identification of assumptions. Global Rationale: The process of data collection involves a systematic approach. The first step in the process involves the identification of assumptions. Assumptions may misguide or misdirect the process of assessment and intervention. Additional steps in the process, in order, include organizing the approach, determining the reliability and accuracy of the information, distinguishing between relevant and irrelevant information, and looking for any inconsistencies in the information. Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.3: Define health assessment. Question 20 Type: MCSA The nurse is preparing a teaching plan for a client diagnosed with type 1 diabetes mellitus. When developing the teaching plan the nurse addresses objectives in the psychomotor domain. Which of the following objectives best meets this criteria? 1. The client will discuss measures to take when experiencing the feeling of low blood glucose levels. 2. The client will describe signs and symptoms of low blood sugar. 3. The client will demonstrate how to draw up the correct dose of insulin. 4. The client will define the dimensions of diabetes mellitus. Correct Answer: 3

Rationale 1: Cognitive objectives include those concerning the acquisition of knowledge. The client’s understanding of actions to take when experiencing low blood glucose levels is an example of a cognitive domain. Rationale 2: The identification of the signs and symptoms of low blood sugar are reflective of the cognitive domain. Rationale 3: The demonstration of skills such as drawing up insulin is reflective of the psychomotor domain. Rationale 4: Defining the dimensions of diabetes mellitus is consistent with the cognitive domain. Global Rationale: In the teaching plan the objectives identify specific, measurable behaviors or activities expected of the client. Action verbs may be from the cognitive, affective, or psychomotor domain. The demonstration of skills such as drawing up insulin is reflective of the psychomotor domain. Psychomotor objectives include the acquisition of skills. The affective domain refers to attitudes, feelings, values, and opinions. The identification of the signs and symptoms of low blood sugar are reflective of the cognitive domain. Cognitive objectives include those concerning the acquisition of knowledge. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.4: Identify the factors to consider in health assessment. Question 21 Type: MCSA Which of the following statements best describes the active role of the professional nurse as an educator? 1. Nurses must consider learning needs, goals, objectives, content, teaching methods, and evaluation when carrying out client education. 2. Teaching plans are developed for informal teaching when distinct needs are identified or when common needs are recognized. 3. In the role of educator, the nurse should refer the client to other health care providers who specialize in the area of need. 4. Teaching is to be delegated to the advanced practice nurse specialist or the nurse educator. Correct Answer: 1 Rationale 1: Roles of the professional nurse include teacher, both formal and informal, caregiver, and client advocate. Rationale 2: Informal teaching does not involve teaching plans. Rationale 3: Roles of the professional nurse include teacher, both formal and informal, caregiver, and client advocate.

Rationale 4: Teaching is often done in collaboration with the advanced practice nurse specialist or the nurse educator. Nurses at the bedside also must share the role of client educator. Global Rationale: Roles of the professional nurse include teacher, both formal and informal, caregiver, and client advocate. The professional nurse may also have advanced practice roles. Informal teaching does not involve teaching plans. Teaching is often done in collaboration with the advanced practice nurse specialist or the nurse educator. Nurses at the bedside also must share the role of client educator. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.7: Describe the role of the professional nurse in health assessment. Question 22 Type: MCSA The charge nurse has instructed the nurse to complete a focused interview on the client who has just been admitted to the facility with complaints consistent with kidney stones. Which of the following actions by the nurse indicates the best understanding of the assignment? 1. The nurse obtains a urine sample to send for a urinalysis. 2. The nurse takes the client’s vital signs. 3. The nurse questions the client about dietary preferences. 4. The nurse asks the client about the characteristics of the pain being experienced. Correct Answer: 4 Rationale 1: The client may need to have a urine specimen that does not directly relate to determining more information about the chief complaints of the client. Rationale 2: 2. The client vital signs will be taken but they do not directly relate to determining more information about the chief complaints of the client. Rationale 3: Dietary preferences of clients are recorded but are not a part of the focused assessment. Rationale 4: The focused interview is used to allow for clarification of information from the initial interview. The goal of the focused interview is to expand the information available. Global Rationale: The focused interview is used to allow for clarification of information from the initial interview. The goal of the focused interview is to expand the information available. The client may need to have a urine specimen and will need vital signs taken but they do not directly relate to determining more information about the chief complaints of the client. Dietary preferences of clients are recorded but are not a part of the focused assessment.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Identify the factors to consider in health assessment. Question 23 Type: MCSA A female client has been admitted to the acute care unit with complaints of abdominal pain, nausea, and vomiting. During the interview the nurse determines the client’s history includes pelvic inflammatory disease, mitral valve prolapse, and childbirth. The assessment finds the client’s vital signs to be within normal limits. When analyzing the available data, what items should be clustered together? 1. Vital signs, complaints of pain history of childbirth 2. Abdominal pain, nausea, vomiting, and history of pelvic inflammatory disease 3. Gender, history of mitral valve prolapse, and vital signs 4. History of pelvic inflammatory disease, mitral valve prolapse, and pain scale reports Correct Answer: 2 Rationale 1: The analysis of assessment data includes clustering or grouping related pieces of information. There is no obvious relationship between these pieces of information. Rationale 2: The analysis of assessment data includes clustering or grouping related pieces of information. The client’s complaints of abdominal pain, nausea, vomiting, and history of pelvic inflammatory disease are interrelated items. Rationale 3: The analysis of assessment data includes clustering or grouping related pieces of information. There is no obvious relationship among these pieces of information. Rationale 4: The analysis of assessment data includes clustering or grouping related pieces of information. There is no obvious relationship among these pieces of information. Global Rationale: The analysis of assessment data includes clustering or grouping related pieces of information. The client’s complaints of abdominal pain, nausea, vomiting, and history of pelvic inflammatory disease are interrelated items. There is no obvious relationship between the remaining pieces of information. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.6: Describe the critical thinking process with relevance to health assessment. Question 24

Type: MCMA The nurse is preparing the care plan for a client who has undergone an abdominal hysterectomy to manage endometriosis. When reviewing goal statements, which of the following reflect the need for further development? Standard Text: Select all that apply. 1. The nurse will assess the vital signs every 2 hours. 2. The client will walk Q2h on the first postoperative day. 3. The client will report feeling better. 4. The client will begin a clear liquid diet on the first postoperative day. 5. The healthcare provider will prescribe oral analgesics on the first postoperative day. Correct Answer: 1,3,5 Rationale 1: The nurse will assess the vital signs every 2 hours. Goal statements are used to provide planned outcomes for the client. Goal statements must be measurable and are reflective of client activities. This statement reflects actions of the nurse, not the client. Rationale 2: The client will walk Q2h on the first postoperative day. The goal statement is used to provide planned outcomes for the client. Goal statements must be measurable and reflective of client activities. All elements needed for an appropriate goal statement are represented. Rationale 3: The client will report feeling better. Goal statements must be measurable and reflective of client activities. This statement is vague and does not provide a definitive means for measurement. Rationale 4: The client will begin a clear liquid diet on the first postpartum day. Goal statements are used to provide planned client outcomes. This statement contains the needed elements for a successful goal statement. Rationale 5: The healthcare provider will prescribe oral analgesics on the first postoperative day. This statement is not a client-centered goal statement. This statement reflects an intervention performed by the healthcare provider. Global Rationale: Goal statements are used to provide planned outcomes for the client. Goal statements must be measurable and are reflective of client activities. The only statement reflecting these criteria is that the client will walk Q2h on the first postoperative day. Statements reflecting actions of the nurse or healthcare provider are not goal statements. Vague statements such as “feeling better” are not measurable. The statement that the client will begin a clear liquid diet on the first postoperative day contains the needed elements for a successful goal statement. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.5: Define the steps of the nursing process.

Question 25 Type: MCSA The community health nurse is preparing a program about health maintenance. The nurse has decided to use the Leavall and Clark model as the framework for the programming. Which of the following program objectives best explain the concepts presented by this model? 1. The participants will recognize health as the absence of disease. 2. The participants will verbalize the role of self-actualization achievement in relation to health. 3. The participants will define health as the interrelationships between the agent, host, and the environment. 4. Internal harmony is the foundational basis for health achievement. Correct Answer: 3 Rationale 1: The absence of disease and internal harmony are not specific independent models for health. Rationale 2: Self-actualization and health are explored in the eudaemonistic model for health. Rationale 3: Leavall and Clark developed the ecologic model for health. This model considers the relationship between the agent, host, and environment as the key determinants for health status. Rationale 4: The absence of disease and internal harmony are not specific independent models for health. Global Rationale: Leavall and Clark developed the ecologic model for health. This model considers the relationship between the agent, host, and environment as the key determinants for health status. Self-actualization and health are explored in the eudaemonistic model for health. The absence of disease and internal harmony are not specific independent models for health. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.1 Discuss the various definitions of health. Question 26 Type: MCSA The nurse educator is discussing the charting used in the facility with a group of recently hired nurses. The facility uses the APIE method of charting. Which of the following responses by one of the newly hired nurses indicates understanding of the charting method? 1. “I will only need to chart by exception with this method.” 2. “Only subjective data are included in the assessment portion.”

3. “The ‘P’ refers to the planning phase of the process.” 4. “The activities implemented to manage the client’s needs will be documented in the ‘I’ section.” Correct Answer: 4 Rationale 1: APIE is not the same as charting by exception. Rationale 2: The APIE method of charting uses the letters to refer to the assessment, problem, intervention, and evaluation. The assessment includes both the objective and subjective data. Rationale 3: The APIE method of charting uses the letters to refer to the assessment, problem, intervention, and evaluation. The “P” refers to the chief problem. Rationale 4: The APIE method of charting uses the letters to refer to the assessment, problem, intervention, and evaluation. “I” includes the interventions implemented to manage the client. Global Rationale: The APIE method of charting involves charting that is problem based. Information documented are only those items that are not within normal limits. The APIE method of charting uses the letters to refer to the assessment, problem, intervention, and evaluation. The assessment includes both the objective and subjective data. The “P” refers to the chief problem. “I” includes the interventions implemented to manage the client. “E” stands for evaluation of the response to the plan of care. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.7: Describe the role of the professional nurse in health assessment. Question 27 Type: MCSA The nurse manager is considering changing the type of charting/documentation done on the client care unit. The nurses have requested a system that will reduce time spent writing out routine tasks and will still allow for documentation of exceptions. Which type of documentation will best meet the needs of the nursing staff? 1. Focus documentation 2. Flow sheets 3. SOAP charting 4. APIE charting Correct Answer: 2 Rationale 1: Focused documentation records client problems and strengths.

Rationale 2: Flow sheets use columns or categories to log in assessment findings and to note interventions performed. Flow sheets reduce repetition and are time efficient. Rationale 3: SOAP charting is detailed and includes subjective and objective data, assessment findings, and planning information. Rationale 4: APIE charting includes assessment, planning, intervention, and evaluation. Global Rationale: Flow sheets use columns or categories to log in assessment findings and to note interventions performed. Focused documentation records client problems and strengths. Flow sheets reduce repetition and are time efficient. Focused documentation records client problems and strengths. SOAP charting is detailed and includes subjective and objective data, assessment findings, and planning information. APIE charting includes assessment, planning, intervention, and evaluation. Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1.7: Describe the role of the professional nurse in health assessment. Question 28 Type: MCMA The student nurse is preparing a care plan for an assigned client. The student correctly recognizes that the nursing diagnosis is composed of which of the following elements? Standard Text: Select all that apply. 1. Medical diagnosis 2. Risk or related factors 3. Defining characteristics 4. A diagnostic label 5. A definition Correct Answer: 2,3,4,5 Rationale 1: Medical diagnosis. The nursing diagnosis is composed of four components. These components are a diagnostic label, definition, defining characteristics, and risks or related factors. A medical diagnosis is not included in the nursing diagnosis. Rationale 2: Risk or related factors. The nursing diagnosis is composed of four components. These components are a diagnostic label, definition, defining characteristics, and risks or related factors.

Rationale 3: Defining characteristics. The nursing diagnosis is composed of four components. These components are a diagnostic label, definition, defining characteristics, and risks or related factors. Rationale 4: A diagnostic label. The nursing diagnosis is composed of four components. These components are a diagnostic label, definition, defining characteristics, and risks or related factors. Rationale 5: A definition. The nursing diagnosis is composed of four components. These components are a diagnostic label, definition, defining characteristics, and risks or related factors. Global Rationale: The nursing diagnosis is composed of four components. These components are a diagnostic label, definition, defining characteristics, and risks or related factors. A medical diagnosis is not included in the nursing diagnosis. Cognitive Level: Remembering Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1.5: Define the steps of the nursing process. Question 29 Type: MCSA The nurse is developing a plan of care for a recently admitted client. The nurse recognizes that the basis for the plan and implementation of care is (are): 1. The nursing diagnosis 2. The objective data 3. The subjective data 4. Client goals Correct Answer: 1 Rationale 1: The nursing diagnosis is the basis for the plan and implementation of care delivered to the client. Rationale 2: Objective and subjective data are collected and used to formulate the nursing diagnosis. Rationale 3: Objective and subjective data are collected and used to formulate the nursing diagnosis. Rationale 4: Client goals are developed to determine the success of the care delivered. Global Rationale: The nursing diagnosis is the basis for the plan and implementation of care delivered to the client. Objective and subjective data are collected and used to formulate the nursing diagnosis. Client goals are developed to determine the success of the care delivered. Cognitive Level: Remembering

Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1.5: Define the steps of the nursing process. Question 30 Type: MCSA During step 3 of the nursing process, which of the following activities is performed? 1. Statement of client goals 2. Collection of subjective data 3. Performance of care activities 4. Review of client goal achievement Correct Answer: 1 Rationale 1: The third step in the nursing process is the planning phase. During the planning phase, care interventions are determined, priorities are set, and client goals are stated. Rationale 2: Collection of subjective data takes place during the first step in the nursing process. Rationale 3: Care activities are implemented during the fourth phase of the nursing process. Rationale 4: During the final stage of the nursing process the client’s progress toward goal achievement is evaluated. Global Rationale: The third step in the nursing process is the planning phase. During the planning phase, care interventions are determined, priorities are set, and client goals are stated. Collection of subjective data takes place during the first step in the nursing process. Care activities are implemented during the fourth phase of the nursing process. During the final stage of the nursing process the client’s progress toward goal achievement is evaluated. Cognitive Level: Remembering Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.5: Define the steps of the nursing process. Question 31 Type: MCSA The nurse is reviewing the following flow chart entries for a client experiencing pain. Which of the following chart entries represents a subjective entry?

1. The client’s leg is red and swollen. 2. The client complains of leg tenderness. 3. The client’s white blood cell count is 5.6. 4. The client demonstrates guarding behaviors during the assessment of the affected extremity. Correct Answer: 2 Rationale 1: Objective information is observable by the examiner. The examiner is able to visualize the appearance of the extremity. Rationale 2: Subjective information refers to data reported by the client. The client’s complaints are an example of subjective information. Rationale 3: The laboratory values are objective data that can be determined by a technician. Rationale 4: Objective information is observable by the examiner. The presence of guarding behaviors may be noted by the examiner. Global Rationale: Subjective information refers to data reported by the client. The client’s complaints are an example of subjective information. Objective information is observable by the examiner. The examiner is able to visualize the appearance of the extremity. The laboratory values are objective data that can be determined by a technician. The presence of guarding behaviors may be noted by the examiner. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Identify factors to consider in a health assessment. Question 32 Type: MCSA The nurse manager is reviewing the following SOAP chart entries for a recently licensed nurse. Which of the following entries indicate that the nurse needs further instruction concerning documentation? 1. S: The client states, “ I am so nauseated.” 2. O: The client reports feeling fatigued. 3. A: Bowel sounds are high-pitched in all abdominal quadrants. 4. P: The client will remain NPO. Correct Answer: 4

Rationale 1: S refers to subjective data. Client reports are examples of subjective information. Rationale 2: S refers to subjective data. Client reports are examples of subjective information. Rationale 3: A refers to assessment. The characteristics of the client’s bowel sounds represents of an assessment. Rationale 4: P refers to planning. Planning indicates actions taken to resolve or address the client’s needs. Global Rationale: SOAP charting is a problem-oriented system of documentation. S refers to subjective data. Client reports are examples of subjective information. O refers to objective data. Objective information is observable by the examiner. Report of fatigue is an example of subjective information. A refers to assessment. The characteristics of the client’s bowel sounds represents an assessment. P refers to planning. Planning indicates actions taken to resolve or address the client’s needs. Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.7: Describe the role of the professional nurse in health assessment.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 2 Question 1 Type: MCSA The nurse is planning a smoking cessation class prior to the upcoming Great American Smokeout, hoping it may motivate many individuals to stop smoking by promoting self-efficacy. Which of the following statements, if made by the client, would indicate the highest level of positive self-efficacy according to the Health Belief Model? 1. “I think this time will be different.” 2. “I am going to do the best that I can, so that I won’t get lung cancer.” 3. “I am afraid of getting lung cancer like my father.” 4. “I know that this time I will quit smoking permanently.” Correct Answer: 4 Rationale 1: Stating that this attempt at quitting smoking will be different shows a low level of commitment to the action. Rationale 2: Stating fear of getting lung cancer represents an internal cue to action, based on the Health Belief Model. Rationale 3: Referring to a family member with the disease represents an internal cue to action, based on the Health Belief Model. Rationale 4: Based on the Health Belief Model, self-efficacy refers to the level of confidence an individual has about the ability to perform the activity. The client’s statement, “I know that this time I will quit smoking permanently,” shows the highest-level determination and motivation. Global Rationale: Based on the Health Belief Model, self-efficacy refers to the level of confidence an individual has about the ability to perform the activity. The client’s statement that he/she intends to make a permanent change shows the highest-level determination and motivation. Stating that this attempt at quitting smoking will be different shows a low level of commitment to the action. Stating fear of getting lung cancer and referring to a family member with the disease represents internal cues to action, based on the Health Belief Model. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3: Discuss perspectives of health promotion for the individual, family, and community. Question 2

Type: MCSA A couple who both have a positive family history of sickle cell anemia are concerned about the potential of having a child with sickle cell disease. Which statement indicates that the couple wishes to participate in primary prevention? 1. “We need to both be treated for sickle cell anemia before we can have a baby.” 2. “We will have blood tests to determine if we are carriers.” 3. “We need to see a genetics counselor to discuss the potential for having a child with sickle cell disease.” 4. “Neither one of us has sickle cell disease, so any baby we have will be safe from the disease as well.” Correct Answer: 3 Rationale 1: Indicating a need for treatment would be considered secondary or tertiary prevention. Rationale 2: Both individuals being tested for carrier status would be considered secondary prevention, as it deals with early diagnosis of health problems. Rationale 3: Primary prevention implies health and a high level of wellness for the individual. Seeking out a genetics counselor to discuss the potential for having a child with sickle cell disease is considered primary prevention. Rationale 4: Stating that neither has the disease, thus a child would not inherit the disease, indicates no level of prevention. Global Rationale: Primary prevention implies health and a high level of wellness for the individual. Seeking out a genetics counselor is considered primary prevention. Indicating a need for treatment would be considered secondary or tertiary prevention. Both individuals being tested for carrier status would be considered secondary prevention, as it deals with early diagnosis of health problems. Stating that neither has the disease, thus a child would not inherit the disease, indicates no level of prevention. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.2: Discuss theories of wellness. Question 3 Type: MCSA The nurse is interviewing a client who has experienced a 15-pound weight gain during the last year. The nurse obtains a 24-hour dietary recall, as well as determines the client’s exercise habits and feelings regarding plans to take off the excess weight. The nurse is using what type of approach with this client to enhance health? 1. Psychosocial perspective

2. Illness perspective 3. Physiologic perspective 4. Wellness perspective Correct Answer: 4 Rationale 1: A psychosocial perspective would not take into account the physiologic alteration necessary for a successful weight loss program. Rationale 2: An illness perspective does not include the positive attributes, such as motivation, that the client possesses to address the 15-pound weight gain during the past year; rather, it focuses on the illnesses, such as hypertension, that can result from the weight gain. Rationale 3: A physiologic perspective could also be considered an illness perspective. Rationale 4: When using a wellness perspective, the nurse focuses on the client’s personal strengths and abilities to enhance health. Global Rationale: When using a wellness perspective, the nurse focuses on the client’s personal strengths and abilities to enhance health. An illness perspective does not include the positive attributes that the client possesses to address the problem. A physiologic perspective could also be considered an illness perspective. A psychosocial perspective would not take into account the physiologic alteration necessary for a successful weight loss program. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.2: Discuss theories of wellness. Question 4 Type: MCSA The nurse is discharging a client who had a CVA and will be cared for at home by her husband. The nurse knows that the client’s husband understands the need for tertiary prevention when he makes which of the following statements? 1. “She will need instruction on using her walker.” 2. “She will need to have her flu shot this year.” 3. “She must take her blood pressure medications regularly.” 4. “She needs to have her cholesterol checked every 2 months.” Correct Answer: 1

Rationale 1: Tertiary prevention involves strategies for rehabilitation; instructing the client on proper use of a walker is an example of tertiary prevention. Rationale 2: Having a flu shot is a primary prevention strategy. Rationale 3: Taking blood pressure medication is secondary prevention since the treatment is aimed at maintaining normal blood pressure and preventing complications from the condition. Rationale 4: Having a cholesterol screening is an example of secondary prevention. Global Rationale: Tertiary prevention involves strategies for rehabilitation, such as using a walker to aid ambulation. Having a flu shot is a primary prevention strategy. Taking blood pressure medication is secondary prevention since the treatment is aimed at maintaining normal blood pressure and preventing complications from the condition. Having a cholesterol screening is also an example of secondary prevention. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.2: Discuss theories of wellness Question 5 Type: MCMA The nurse is planning a weight reduction class and wants to use the Health Belief Model to motivate the clients in losing weight. The nurse would correctly choose which of the following as mediating factors in the Health Belief Model? Standard Text: Select all that apply. 1. Likelihood of the individuals developing complications from being overweight 2. The clients’ perception of the severity of an illness that could develop from being overweight 3. The cost of the class that will be the client’s responsibility 4. The amount of time commitment for the individuals taking the class 5. The religion of the clients who will be taking the class Correct Answer: 1,2,3,4 Rationale 1: Susceptibility refers to how likely an individual is to develop an illness or condition and it is one of the mediating factors according to the Health Belief Model; the likelihood of the individuals developing complications from being overweight is an example.

Rationale 2: The perceived severity of an illness is the second mediating factor that determines the motivation to participating in health-promotion behaviors. The clients’ perception of the severity of an illness that could develop from being overweight is an example. Rationale 3: The actual cost of the class would be considered the physical cost of the health-promoting activity versus continuing the unhealthy behavior. Physical and psychologic perceived cost is the fourth mediating variable. Rationale 4: Time commitment necessary for the class would be considered a psychologic cost of the health promoting activity versus continuing the unhealthy behavior. Physical and psychologic perceived cost is the fourth mediating variable. Rationale 5: Religion is not identified as one of the mediating variable according to the Health Belief Model. Global Rationale: Mediating factors affect the health-promoting behaviors by influencing the perception of susceptibility, severity, effectiveness, and cost (physical and psychologic). Religion is not one of the identified mediating factors according to the Health Belief Model. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2.3: Discuss perspectives of health promotion for the individual, family, and community. Question 6 Type: MCSA The nurse is part of a committee examining ways to most effectively meet the goals of Healthy People 2020. Which of the following clients would be the nurse’s highest priority client? 1. A 16-year-old girl with her first pregnancy 2. A diabetic client who maintains optimal visual intactness 3. An IV drug abuser who converts to methadone use 4. Several obese school-age children Correct Answer: 2 Rationale 1: A 16 year old with a pregnancy does not indicate healthy behavior across the life span. Rationale 2: The diabetic client maintaining visual intactness demonstrates the overall goal of Healthy People 2020 through practicing healthy behavior in regards to controlling his diabetes and improved long-term quality of life. Rationale 3: An IV drug user still using a drug does not demonstrate healthy behavior, nor improved quality of life or elimination of health inequities.

Rationale 4: Obesity levels in the school-aged population do not demonstrate healthy behavior across the life span. Global Rationale: The overriding goals for Healthy People 2020 are to eliminate preventable diseases and health inequities, as well as promotion of healthy behavior across the entire life span of an individual. The diabetic client maintaining visual intactness demonstrates healthy behavior in regards to controlling his diabetes and improved long-term quality of life. A 16 year old with a pregnancy does not indicate healthy behavior across the life span. An IV drug user still using a drug does not demonstrate healthy behavior, nor improved quality of life or elimination of health inequities. Obesity levels in the school-aged population do not demonstrate healthy behavior across the life span. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 7 Type: MCMA The nurse is planning an exercise class for a group of young adults. Which of the following would the nurse include as benefits of regular physical activity? Standard Text: Select all that apply. 1. Reduced risk of cardiovascular disease 2. Reduced risk of skin cancer 3. Reduced risk of colon cancer 4. Reduced risk of renal disease 5. Reduced risk of hypertension Correct Answer: 1,3,5 Rationale 1: Regular physical activity has been found to decrease the risk of developing or dying from cardiovascular disease. Rationale 2: The development of skin cancer is not related to physical activity. Rationale 3: Regular physical activity has been found to decrease the risk of developing or dying from colon cancer. Rationale 4: The development of renal disease is not related to physical activity.

Rationale 5: Regular physical activity has been found to decrease the risk of developing or dying from hypertension. Global Rationale: According to Healthy People 2020, regular physical activity results in a decreased risk of cardiovascular disease, colon cancer, and hypertension. It does not result in decreasing the risk of skin cancer or renal disease. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 8 Type: MCSA The school nurse is working with several teenagers in gym class. Which of the following individuals would the nurse know is meeting the age-appropriate recommendations for physical activity developed by the Centers for Disease Control? 1. A 17 year old who runs at a fast pace for 30 minutes 5 times per week and practices yoga for 30 minutes 2 times per week 2. A 16 year old who swims for 60 minutes 5 times per week and jogs for 60 minutes the other 2 days per week 3. A 15 year old who lifts moderately heavy weights 15 minutes 3 times per week 4. A 13 year old who speed-walks 60 minutes 5 times per week Correct Answer: 2 Rationale 1: Running for 30 minutes 5 times per week and practicing yoga for 30 minutes 2 times per week does not meet the CDC recommendation of 1 hour of moderate to vigorous exercise daily for children and adolescents ages 6 to 17. Rationale 2: Swimming for 60 minutes 5 times per week and jogging for 60 minutes the remaining 2 days per week meets the CDC recommendation of 1 hour of moderate to vigorous exercise daily for children and adolescents ages 6 to 17. Rationale 3: Lifting weights for 15 minutes 3 times per week does not meet the CDC recommendation of 1 hour of moderate to vigorous exercise daily for children and adolescents ages 6 to 17. Rationale 4: Speed-walking for 60 minutes 5 times per week does not meet the CDC recommendation of 1 hour of moderate to vigorous exercise daily for children and adolescents ages 6 to 17. Global Rationale: The CDC recommendation for physical activity for children and adolescents, ages 6 to 17, are: 1 hour or more of physical activity every day with most of the hour consisting of moderate- or vigorous-intensity aerobic activity. The CDC also recommends that during the daily hour of physical activity, muscle-strengthening

activity and bone-strengthening activity should each be included at least 3 days per week. Therefore, the 16 year old who swims for 1 hour 5 days per week and jogs for 60 minutes the remaining 2 days per week meets the CDC recommendations. The swimming would also be considered a muscle-strengthening activity and the jogging would be considered a bone-strengthening activity. The other options do not meet CDC recommendations. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 9 Type: MCSA The school nurse is working with several school-aged children in health class. Which of the following individuals would the nurse know is most closely meeting the age-appropriate recommendations for physical activity developed by the Centers for Disease Control? 1. A 12 year old who plays soccer 4 days per week at the neighborhood playground and 3 days per week for a soccer team 2. A 10 year old who runs wind sprints for 15 minutes for PE class 1 day per week 3. A 8 year old who plays on the monkey bars at both 30-minute recess periods 3 times per week 4. A 9 year old who plays kickball at one 20-minute recess daily 5 times per week and plays basketball for a team 2 days per week Correct Answer: 1 Rationale 1: The 12 year old who plays soccer 4 days per week at the neighborhood playground and 3 days per week for a soccer team is meeting the recommended 60 minutes per day of moderate- to vigorous-intensity aerobic activity. Rationale 2: The 10 year old who runs wind sprints for 15 minutes for PE class 1 day per week is not meeting the recommended 60 minutes per day of moderate- to vigorous-intensity aerobic activity. Rationale 3: The 8 year old who plays on the monkey bars at both 30-minute recess periods 3 times per week is not meeting the recommended 60 minutes per day of moderate- to vigorous-intensity aerobic activity. Rationale 4: The 9 year old who plays kickball at one 20-minute recess daily 5 times per week and plays basketball for a team 2 days per week is not meeting the recommended 60 minutes per day of moderate- to vigorous-intensity aerobic activity. Global Rationale: The CDC recommendation for physical activity for children and adolescents, ages 6 to 17, are: 1 hour or more of physical activity every day with most of the hour consisting of moderate- or vigorous-intensity aerobic activity. The CDC also recommends that during the daily hour of physical activity, muscle strengthening activity and bone-strengthening activity should each be included at least 3 days per week. Only the child who

plays soccer each day meets the recommended activity levels for age. The 10 year old is exercising only 15 minutes once per week. The 8 year old is exercising 60 minutes per day, but only three times per week, which does not meet the criteria for 60 minutes of daily exercise. The 9 year old is only exercising for 20 minutes 5 days while playing kickball and 2 days of basketball, which does not meet the minimum criteria. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 10 Type: MCSA The nurse is teaching a smoking cessation class and has included the following statements in the presentation: “Everyone here tonight has the ability to control the urge to smoke. You are all rational people who understand that smoking is the cause of many significant health problems, and that it is a voluntary event that you are going to learn to do without. Regardless of your motivation, you will get help here to understand your triggers to smoke, and how to control them.” The nurse is utilizing what type of theory/model to promote smoking cessation? 1. The Self-Efficacy Model 2. The Theory of Reasoned Action 3. The Health Promotion Model 4. The Health Belief Model Correct Answer: 2 Rationale 1: Self-efficacy is part of the Health Belief Model, and not its own theory. Self-efficacy refers to how confident individuals are in their own ability to perform a behavior. Rationale 2: The Theory of Reasoned Action/Planned Behavior is a prediction theory based on the assumptions that behavior is under volitional control and that people are rational beings. The theory also suggests that individuals are more likely to participate in healthy behaviors if they believe the benefit outweighs the cost of the behavior. The statement by the nurse indicates these principles. Rationale 3: The Health Promotion Model depicts people as multidimensional in interactions with their environments and focuses on variables that impact behavior. Variables that impact behavior include personal factors such as age, strength, and agility; cognitive factors such as an individual’s perceived benefit of a health promoting action; and intrapersonal influences such as the influence of family members, friends, or a health care provider. The statement by the nurse does not depict this model. Rationale 4: The Health Belief Model relates to cues to action for a change in behavior. The cues to action in this model refer to internal and external stimuli that motivate a person to participate in health promoting behavior. An example of a cue to action is a female getting yearly mammograms due to a family member having breast cancer. The statement by the nurse does not depict this model.

Global Rationale: The Theory of Reasoned Action / Planned Behavior is a prediction theory based on the assumptions that behavior is under volitional control and that people are rational beings. The theory also suggests that individuals are more likely to participate in healthy behaviors if they believe the benefit outweighs the cost of the behavior. Self-efficacy refers to how confident individuals are in their own ability to perform a behavior, and is part of the Health Belief Model, not its own theory. The Health Promotion Model depicts people as multidimensional in interactions with their environments and focuses on variables that impact behavior. Variables that impact behavior include personal factors such as age, strength, and agility; cognitive factors such as an individual’s perceived benefit of a health-promoting action; and intrapersonal influences such as the influence of family members, friends, or a health care provider. The Health Belief Model relates to cues to action. The cues to action in this model refer to internal and external stimuli that motivate a person to participate in health-promoting behavior. An example of a cue to action is a female getting yearly mammograms due to a family member having breast cancer. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.3: Discuss perspectives of health promotion for the individual, family, and community. Question 11 Type: MCSA The nurse is working with several clients in a fitness setting. Which of the following individuals would the nurse know is meeting the age-appropriate recommendations for physical activity developed by the Centers for Disease Control? 1. A 37 year old who lifts weights for one hour twice per week 2. A 42 year old who walks at a slow pace for 60 minutes 4 days per week 3. A 45 year old who walks briskly for 30 minutes 6 days per week 4. A 57 year old who swims for 20 minutes twice per week Correct Answer: 3 Rationale 1: The weight lifter is not exercising the minimum number of hours per week of the recommended moderate-intensity physical activities for at least 2 hours and 30 minutes per week or 1 hour and 15 minutes of vigorous-intensity aerobic physical activity per week; or an equivalent combination of moderate- and vigorousintensity aerobic activity. Rationale 2: The 42 year old who is walking at a slow pace is not meeting the minimum criteria for moderate exercise. Rationale 3: The adult who walks briskly for 30 minutes 6 days per week is meeting the criteria of moderateintensity physical activities for at least 2 hours and 30 minutes per week or 1 hour and 15 minutes of vigorousintensity aerobic physical activity per week; or an equivalent combination of moderate- and vigorous-intensity

aerobic activity, as well as the suggested aerobic activity occurring for at least 10 minute episodes throughout the week. Rationale 4: The swimmer is only exercising twice per week for a total of 40 minutes, which does not meet the minimum requirements for moderate physical activity. Global Rationale: The recommendations for physical activity for adults are: moderate-intensity physical activities for at least 2 hours and 30 minutes per week or 1 hour and 15 minutes of vigorous-intensity aerobic physical activity per week or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Aerobic activity should occur for at least 10-minute episodes throughout the week. Only the adult who walks briskly is meeting the criteria of moderate-intensity physical activities for at least 2 hours and 30 minutes per week or 1 hour and 15 minutes of vigorous-intensity aerobic physical activity per week or an equivalent combination of moderate- and vigorous-intensity aerobic activity. The weight lifter is not exercising the minimum number of hours per week. The 42 year old who is walking at a slow pace is not meeting the minimum criteria for moderate exercise. The swimmer is only exercising twice per week for a total of 40 minutes. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 12 Type: MCSA The nurse is working with a client in a fitness setting. Which of the following would be the correct maximum desired heart rate target zone for both moderate- and vigorous-intensity workouts for this 60-year-old female? 1. 66–80, and 112–124 2. 60–85, and 85–110 3. 80–110, and 120–130 4. 80–112, and 112–136 Correct Answer: 4 Rationale 1: Utilizing the proper calculation method, 66–80, and 112–124 beats per minute are not the desired heart rate target zones for moderate- and vigorous-intensity workouts for a 60 year old. Rationale 2: Utilizing the proper calculation method, 60–85, and 85–110 beats per minute are not the desired heart rate target zones for moderate- and vigorous-intensity workouts for a 60 year old. Rationale 3: Utilizing the proper calculation method, 80–110, and 120–130 beats per minute are not the desired heart rate target zones for moderate- and vigorous-intensity workouts for a 60 year old.

Rationale 4: Utilizing the proper calculation method, 80–112, and 112–136 beats per minute are the desired heart rate target zones for moderate- and vigorous-intensity workouts for a 60 year old. Global Rationale: Moderate intensity exercise should raise the heart rate 50–70%. Vigorous intensity exercise should raise the heart rate 70–85%. To calculate the minimum and maximum targets zones from each type of activity, you must first determine the maximum heart rate. This is done by subtracting the individual’s age from 220. Therefore, 220 – 60 = 160. 160 x 0.5 (50%) = 80. 160 x 0.7 (70%) = 112. For vigorous activity, 160 x 0.7 = 112. 160 x 0.85 (85%)= 136. Therefore, 80–112 and 112–136 is the correct answer. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 13 Type: MCSA The nurse understands that the type of exercise that is most useful for strengthening larger muscle groups such as abdominals, gluteals, and quadriceps, and for endurance training is: 1. Aerobic 2. Isotonic 3. Resistive 4. Isometric Correct Answer: 4 Rationale 1: Aerobic exercises refer to activities in which oxygen is metabolized to produce energy. Examples of aerobic activity include walking, jogging, swimming, and skating. Rationale 2: Isotonic exercises increase tone, and involve activities such as running, walking, and cycling. Rationale 3: Resistive exercises use resistance. An example of resistive exercise includes weight lifting. Rationale 4: Isometric exercises include those that affect muscle tension but do not result in muscle or joint movement. Isometric exercises are useful for strengthening abdominal, gluteal, and quadriceps muscles, for maintaining strength of immobilized muscles, and for endurance training. Examples of isometric exercise would include tensing of thigh muscles and extending the arms and pushing against a wall. Global Rationale: Isometric exercises include those that affect muscle tension but do not result in muscle or joint movement. Isometric exercises are useful for strengthening abdominal, gluteal, and quadriceps muscles, for maintaining strength of immobilized muscles, and for endurance training. Examples of isometric exercise would include tensing of thigh muscles and extending the arms and pushing against a wall. Aerobic exercises refer to activities in which oxygen is metabolized to produce energy. Examples of aerobic activity include walking,

jogging, swimming, and skating. Isotonic exercises increase tone, and involve activities such as running, walking, and cycling. Resistive exercises use resistance. An example of resistive exercise includes weight lifting. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 14 Type: MCSA The nurse is aware that which of the following is responsible for more deaths in the United States than all of the others combined? 1. HIV and AIDS 2. Cigarette smoking 3. Automobile crashes 4. Drug abuse Correct Answer: 2 Rationale 1: HIV and AIDS are not responsible for the most deaths in the United States. Rationale 2: Cigarette smoking is responsible for more deaths in the United States than death from HIV/AIDS, drug abuse, homicide, suicide, automobile crashes, and fire combined. Rationale 3: Automobile crashes are not responsible for the most deaths in the United States. Rationale 4: Drug abuse is not responsible for the most deaths in the United States. Global Rationale: Cigarette smoking is responsible for more deaths in the United States than death from HIV/AIDS, drug abuse, homicide, suicide, automobile crashes, and fire combined. Smoking is a risk factor for heart disease, breathing disorders, and lung cancer. Secondary smoke increases the incidence of asthma and bronchitis in children, and heart and lung diseases in adults. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 15 Type: MCSA

A nursing student is preparing an educational program concerning breast cancer. The focus of the program is primary prevention. Which of the following topics would be most appropriate? 1. A dietary discussion concerning the connection between breast cancer and dietary intake 2. Techniques for performing self–breast examination 3. American Cancer Society recommendations for mammography 4. Treatment options available for breast cancer clients Correct Answer: 1 Rationale 1: Primary prevention implies that an individual is healthy and focuses on health promotion and disease prevention. Primary prevention is demonstrated by the discussion of dietary recommendations for prevention of breast cancer. Rationale 2: Secondary prevention emphasizes early diagnosis and treatment of health problems and includes screenings such as teaching clients about self–breast examination. Rationale 3: Secondary prevention emphasizes early diagnosis and treatment of health problems and includes screenings such as mammography recommendations. Rationale 4: Tertiary prevention is aimed toward treatment of a condition and restoration of health to the highest level of wellness possible. Treatment options for breast cancer would be considered a form of tertiary prevention. Global Rationale: Primary prevention has a focus geared toward health promotion and disease prevention, which is demonstrated by the discussion of dietary recommendations. Secondary prevention emphasizes early diagnosis and treatment of health problems and includes screenings such as teaching clients about self–breast examination and mammography. Tertiary prevention is aimed toward treatment of a condition and restoration of health to the highest level of wellness possible. Treatment options for breast cancer would be considered a form of tertiary prevention. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.2: Discuss theories of wellness. Question 16 Type: MCSA During a routine health examination, a client reports concern about her potential for the development of heart disease. During the assessment, the nurse reviews the client’s risk factors. Which of the following assessed risk factors are considered modifiable? 1. Age, heredity, and weight

2. Family history, self history of diabetes mellitus type I, and age 3. Weight, dietary intake, and environmental risks 4. Biological characteristics, lifestyle factors, and family history Correct Answer: 3 Rationale 1: Age and heredity are nonmodifiable risk factors (cannot be changed by the client’s actions); while weight is a modifiable risk factor (can be changed by the client’s actions). Rationale 2: Family history, self history of diabetes mellitus type I, and age are all nonmodifiable risk factors (cannot be changed by the client’s actions). Rationale 3: Weight, dietary intake, and environmental risks are all modifiable risk factor (can be changed by the client’s actions). Rationale 4: Biological characteristics and family history are nonmodifiable risk factors (cannot be changed by the client’s actions); while lifestyle factors are modifiable risk factors (can be changed by the client’s actions). Global Rationale: Risk factors that can be controlled by client action are termed modifiable. Those risk factors which cannot be changed by the client, such as age, heredity, genetic factors, certain health conditions, and biological characteristics, are called nonmodifiable factors. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3: Discuss perspectives of health promotion for the individual, family, and community. Question 17 Type: MCSA The Health Promotion Model is being used by a nurse to analyze the potential impact of an educational program being provided regarding the importance of regular exercise. According to the model, which of the following participants is most likely to initiate and consistently participate in a successful program of exercise after attending the session? 1. An overweight female who has never participated in an exercise program 2. A 30-year-old male who admits frequently joining and quitting exercise groups 3. A teenaged male who has low self-esteem 4. A 24-year-old female who reports she is anxious to begin exercising with her husband Correct Answer: 4

Rationale 1: The overweight female who has never participated in an exercise program would most likely have less motivation to initiate and consistently participate in a successful exercise program than the 24-year-old female who is anxious to begin exercise with her husband, who would be a source of support, according to the Health Promotion Model. Rationale 2: A 30-year-old male who frequently joins and quits exercise groups is less likely to initiate and consistently participate in a successful exercise program than the 24-year-old female who is anxious to begin exercise with her husband, who would be a source of support, according to the Health Promotion Model. Rationale 3: A teenaged male with low self-esteem is less likely to initiate and consistently participate in a successful exercise program than the 24-year-old female who is anxious to begin exercise with her husband, who would be a source of support, according to the Health Promotion Model. Rationale 4: The 24-year-old female who reports she is anxious to begin exercising with her husband displays the motivational characteristics of the Health Promotion Model to most likely initiate and consistently participate in a successful exercise program. Global Rationale: The Health Promotion Model views persons as “multidimensional and in interaction with interpersonal and physical environments as they pursue health.” The model can be used to make inferences about people’s motivational and behavioral outcomes. The female who has a strong motivation and social support demonstrates the strongest likelihood of following through with the program. Variables such as low self-esteem, prior negative outcomes, and a lack of experience can reduce the individual’s willingness to engage in the healthpromoting activities. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.5: Discuss health promotion in relation to the nursing process. Question 18 Type: MCMA The nurse is planning a presentation to a group of middle-school students regarding health promotion and wellness. The nurse would be correct in planning to discuss which of the following concepts with the students: Standard Text: Select all that apply. 1. Individuals are more knowledgeable in today’s society in regard to health care issues. 2. 2. Consumers of health care in today’s society demonstrate less decision-making capabilities concerning their health care than in the past. 3. The focus of Healthy People 2020 is on the early treatment of disease and pathologic conditions. 4. The roles of health care providers in today’s society have expanded.

5. Individuals, in general, are proactive regarding health care practices and desire care that promotes health and prevents disease. Correct Answer: 1,4,5 Rationale 1: Individuals in today’s society are more knowledgeable regarding health care issues than in the past. Rationale 2: Clients are actively involved in the decision-making process related to their health care. Rationale 3: The focus of Healthy People 2020 is on health promotion and disease prevention rather than early treatment of disease and pathologic conditions. Rationale 4: Due to the complexity of the health care system of today, the role of health care providers has changed and expanded. Rationale 5: Individuals in today’s society are proactive in regard to their health care needs and an emphasis is placed on health promotion and disease prevention. Global Rationale: Individuals in today’s society are more knowledgeable in regard to health care issues; thus, individuals demonstrate control in decision-making capabilities concerning their health care. Healthy People 2020 focuses on health and wellness, rather than early treatment of disease and pathologic conditions. Due to the complexity of today’s health care system, the role of health care providers has changed and expanded. Lastly, individuals are more proactive in regard to health care practices of today and desire care that emphasizes health promotion. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.1: Describe the concepts of wellness and health promotion. Question 19 Type: MCSA A client who has recently experienced a fracture is concerned about maintaining muscle strength during recuperation. The nurse should encourage the client to perform which of the following activities? 1. Isometric exercises 2. Isotonic exercises 3. Resistive exercises 4. Anaerobic exercises Correct Answer: 1

Rationale 1: Isometric exercises affect muscle tension. Joint movement does not occur during isometric exercises. This type of exercise can be used for strength maintenance for immobilized clients and can be achieved with tensing the muscles in the affected arm or extending the arm. Rationale 2: Isotonic exercises increase tone and involve activities such as running, walking, and cycling. These types of activities may be contraindicated by clients having a fracture. Rationale 3: Resistive exercises use resistance. An example of resistive exercise includes weight lifting. This activity may be contraindicated by a client with a fracture. Rationale 4: Anaerobic exercises are activities used to promote endurance training by participating in short periods of vigorous activity. This type of activity would not be indicated for a client with a fracture. Global Rationale: Isometric exercises affect muscle tension. Joint movement does not occur during isometric exercises. Examples of isometric exercise would include tensing of thigh muscles and extending the arms and pushing against a wall. For this client, the best isometric exercise would be tensing the muscles in the affected arm or extending the arm. This type of exercise can be used for strength maintenance for immobilized clients. Isotonic exercises increase tone and involve activities such as running, walking, and cycling. These types of activities may be contraindicated by clients having a fracture. Resistive exercises use resistance. An example of resistive exercise includes weight lifting. Anaerobic exercises are activities used to promote endurance. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.5: Discuss health promotion in relation to the nursing process. Question 20 Type: MCMA The client reports having difficulty sleeping at night. The client asks the nurse for suggestions to assist him in getting a good night’s sleep. Which of the following recommendations may be beneficial to the client? Standard Text: Select all that apply. 1. Perform a short exercise routine 30 minutes prior to going to bed to promote fatigue. 2. Set a regular bedtime. 3. Establish a relaxation routine at bedtime. 4. Avoid alcohol. 5. Watch television to assist in falling asleep. Correct Answer: 2,3,4

Rationale 1: Performing exercises 30 minutes prior to going to bed will most likely stimulate the individual rather than promote sleep. Rationale 2: Setting a regular bedtime, as well as a regular waking time, promotes a more restful sleep. Rationale 3: A relaxation routine prior to bedtime promotes sleep. Rationale 4: Avoiding alcohol will promote restful sleep since alcohol interferes with a normal sleep pattern. Rationale 5: Watching television prior to attempting to fall asleep will most likely stimulate the individual rather than promote sleep. Global Rationale: Establishing a routine including a regular bedtime and relaxation promote a restful sleep. Alcohol may be associated with altered sleep patterns. Performing exercises prior to going to bed and watching television will stimulate the individual rather than promote sleep. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.5: Discuss health promotion in relation to the nursing process. Question 21 Type: MCSA During a routine well-child health examination, the parents of a 4-year-old child report being concerned their child is not getting enough rest. The nursing assessment reveals the child usually gets 9 hours of sleep per night. Which of the responses by the nurse is most appropriate? 1. “The recommendation for children of this age is at least 11 hours per night.” 2. “Your child should be fine with the 9 hours he is getting.” 3. “Taking a nap will benefit your child.” 4. “I would not recommend making any bedtime changes for your child.” Correct Answer: 1 Rationale 1: Sleeping 11 to 13 hours per night is recommended for children ages 3 to 5 years. This child is not receiving the recommended hours of sleep necessary for a 4 year old; therefore, the nurse’s response is correct. Rationale 2: The nurse’s response is incorrect since 9 hours of sleep per night is under the recommended 11 to 13 hours for a 4-year-old child. Rationale 3: Napping will not meet the recommended 11 to 13 hours of sleep for a 4-year-old child who is receiving only 9 hours of sleep per night; therefore, the nurse’s response is incorrect.

Rationale 4: This response is incorrect since the child is not receiving the recommended 11 to 13 hours of sleep per night. Global Rationale: The sleep requirement for a child of this age is 11 to 13 hours per night. Nine hours does not meet the recommendations. Napping does not meet the child’s needs. Changes appear to be warranted for this child. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 22 Type: MCSA The parents of a 7–month-old child, being seen at the clinic for the administration of a hepatitis B vaccine, ask if their child be can also be given a vaccine to prevent the chickenpox during this visit. The best response by the nurse is: 1. “It will be less stressful to administer both shots during this visit.” 2. “The additional injection will make your child run a fever.” 3. “You really should wait and come back next month for this immunization.” 4. “This immunization is not offered until after the age of 12 months.” Correct Answer: 4 Rationale 1: This response by the nurse is incorrect since the first dose of varicella vaccine cannot be given until 12 to 15 months of age. Rationale 2: This response by the nurse is incorrect since the first dose of varicella vaccine cannot be given until 12 to 15 months of age. Rationale 3: The child will only be 8 months old if returning to the office in one month; therefore, this response by the nurse is incorrect since the first dose of varicella vaccine cannot be given until 12 to 15 months of age. Rationale 4: This response by the nurse is correct since the first dose of varicella vaccine cannot be given until 12 to 15 months of age. Global Rationale: The first dose of varicella vaccine is given at 12 to 15 months of age. Providing the vaccine prior to that time is contraindicated. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 23 Type: MCSA The nurse is performing a health assessment. Which of the questions will provide the greatest assistance in the determination of discharge planning needs? 1. “Do you live alone?” 2. “Did you graduate from high school?” 3. “Are you involved in any types of exercise programs?” 4. “What steps have you taken to ensure your care when you go home?” Correct Answer: 4 Rationale 1: This question is a closed question that limits the responses of the client to a “yes” or “no” answer and will prevent the nurse from determining the discharge planning needs of this client. Rationale 2: This question is a closed question that limits the response of the client to a “yes” or “no” answers and will prevent the nurse from determining discharge planning needs of this client. Rationale 3: Information regarding whether or not the client is involved in an exercise program will not help the nurse in determining the client’s discharge planning needs. Rationale 4: “What steps have you taken to ensure your care when you go home?” is an open-ended question that will allow the nurse to determine the client’s discharge planning needs. Global Rationale: Open-ended questions will solicit the greatest amount of information for discharge planning needs. Options 1 and 2 represent closed questions. The determination of participation in exercise programs will not provide information concerning discharge planning needs. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.5: Discuss health promotion in relation to the nursing process. Question 24 Type: MCSA A group of clients attend an educational program at which prevention and screening activities for breast cancer is discussed. Using the Health Belief Model, which participant is most likely to engage in the available health screenings?

1. The client whose mother and grandmother have a history of breast cancer 2. The client who is attending the program as a course requirement 3. The client attending in support of the presenter 4. The client who agreed to attend in support of another participant Correct Answer: 1 Rationale 1: According to the Health Belief Model, mediating variables determine the likelihood of an individual to actively participate in prevention of illness. The client whose family members have a history of breast cancer is most vulnerable to the disease and is thus most likely to engage in the available health screenings. Rationale 2: According to the Health Belief Model, the client who is attending the program as a course requirement will be less influenced to participate in the health screenings than the client who has the positive family history of breast cancer. Rationale 3: According to the Health Belief Model, the client who is attending the program in support of the presenter will be less influenced to participate in the health screenings than the client who has the positive family history of breast cancer. Rationale 4: According to the Health Belief Model, the client who agreed to attend the program in support of another participant will be less influenced to participate in the health screenings than the client who has the positive family history of breast cancer. Global Rationale: According to the Health Belief Model, mediating variables determine the likelihood of an individual to actively participate in prevention of illness. The client whose family members have a history of breast cancer is most vulnerable to the disease and is thus most likely to engage in the available health screenings. The remaining participants do not have the same high level of mediating factors to influence their participation. The client who is attending the program as a course requirement will be less influenced to participate in the health screenings than the client who has the positive family history of breast cancer. Similarly, the client who is attending the program in support of the presenter and the client who agreed to attend the program in support of another participant will be less influenced to participate in the health screenings than the client who has the positive family history of breast cancer. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3: Discuss perspectives of health promotion for the individual, family, and community. Question 25 Type: MCSA The nurse is counseling a 52-year-old female client who has been instructed by her healthcare provider to have a screening mammogram performed. The nurse outlines this procedure for the client as which type of prevention?

1. Primary 2. Tertiary 3. Prepathologic 4. Secondary Correct Answer: 4 Rationale 1: Primary prevention implies health and high level wellness prior to the development of a disease or pathology. Examples of primary prevention include immunizations and eating a healthy diet. Screening mammograms are considered secondary prevention. Rationale 2: Tertiary prevention occurs following the development of a disease or pathologic condition and is aimed at restoring an individual to the highest level of health possible. An example of tertiary prevention would be physical rehabilitation therapy for a client who has had a stroke. Screening mammograms are considered secondary prevention. Rationale 3: Prepathologic prevention is the same as primary prevention, which implies health and high-level wellness prior to the development of a disease or pathology. Examples of primary prevention include immunizations and eating a healthy diet. Screening mammograms are considered secondary prevention. Rationale 4: The goals of secondary prevention are early diagnosis and prompt treatment of health problems. Examples of secondary prevention include screenings such as mammograms, blood tests, surgery, and dental care. Global Rationale: Secondary prevention involves early diagnosis of health problems. Due to an increased risk of breast cancer in women over 50, routine screening is recommended yearly. Screening mammograms are considered secondary prevention. Other examples of secondary prevention include screenings such as blood tests, surgery, and dental care. Prepathologic is another name for primary prevention, which implies health and highlevel functioning prior to development of pathology. Examples of primary prevention include immunizations and eating a healthy diet. Tertiary prevention occurs following the development of a disease or pathologic condition and is aimed at restoring an individual to the highest level of health possible. An example of tertiary prevention would be physical rehabilitation therapy for a client who has had a stroke. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2.2: Discuss theories of wellness. Question 26 Type: MCMA The nurse is planning to develop a campaign to raise awareness on the benefits of regular physical activity. Based on Healthy People 2020 reports, the nurse should target which of the following populations? Standard Text: Select all that apply.

1. Individuals of Hispanic descent attending English as a Second Language course 2. Individuals who are enrolled in a master’s degree program at a local college 3. Females attending a mother’s support group ranging from ages 25 to 35 years 4. Males employed at an investment company ranging from ages 35 to 45 years 5. Adolescents participating in after-school programs for low-income families Correct Answer: 1,3,5 Rationale 1: Individuals of Hispanic descent attending English as a Second Language course. These individuals fall into one of the groups identified by Healthy People 2020 as getting less physical activity than other populations. Rationale 2: Individuals who are enrolled in a master’s degree program at a local college. These individuals do not fall into one of the groups identified by Healthy People 2020 as getting less physical activity than other populations. Rationale 3: Females attending a mother’s support group ranging from ages 25 to 35 years. These individuals fall into one of the groups identified by Healthy People 2020 as getting less physical activity than other populations. Rationale 4: Males employed at an investment company ranging from ages 35 to 45 years. These individuals do not fall into one of the groups identified by Healthy People 2020 as getting less physical activity than other populations. Rationale 5: Adolescents participating in after-school programs for low-income families. These individuals fall into one of the groups identified by Healthy People 2020 as getting less physical activity than other populations. Global Rationale: According to reports in Healthy People 2020, individuals who get the least amount of physical activity include women, lower income and lower educated populations, and African American and Hispanic populations. Therefore, the nurse would be most effective in targeting the individuals of Hispanic descent who are attending English as a Second Language course, the group of females attending a mother’s support group, and the adolescents participating in after school programs for low-income families. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4: Describe goals, topic areas, and objectives in Healthy People 2020. Question 27 Type: MCSA

The nurse is working with an older adult client who has osteoarthritis that affects the mobility of both hips. In developing a plan of care, the nurse must consider the recommended levels of physical activity according to the CDC. The best goal for this client is: 1. The client will bicycle at 10 mph for 1 hour or more every day. 2. The client will jog for 15 minutes per day 5 days per week. 3. The client will walk at least 5 mph for 15 minutes per day. 4. The client will swim for 15 minutes per day 5 days per week. Correct Answer: 4 Rationale 1: Bicycling at 10 mph for 1 hour or more every day is considered vigorous physical activity according to the CDC guidelines and would most likely place excess strain on the client’s hip joints that are affected by the osteoarthritis. Rationale 2: Jogging for 15 minutes per day 5 days per week is considered vigorous physical activity according to the CDC guidelines and would place excess strain on the client’s hip joints that are affected by the osteoarthritis. Rationale 3: Walking at least 5 mph for 15 minutes per day is considered vigorous physical activity according to the CDC guidelines and would most likely place excess strain on the client’s hip joints that are affected by the osteoarthritis. Rationale 4: The CDC recommends that older adults follow the same guidelines for physical activity as adults (moderate intensity physical activity at least 2 hours and 30 minutes per week or 1 hour and 15 minutes of vigorous activity or a combination of moderate and vigorous physical activity per week); if chronic conditions cause limitations, older adults should participate in as much physical activity as their condition allows. Swimming would place the least amount of strain on the hip joints affected by the osteoarthritis, and 15 minutes per day 5 days per week is moderate physical activity that would help maintain joint mobility. Global Rationale: The CDC recommends that older adults follow the same guidelines for physical activity as adults (moderate intensity physical activity at least 2 hours and 30 minutes per week or 1 hour and 15 minutes of vigorous activity or a combination of moderate and vigorous physical activity per week); if chronic conditions cause limitations, older adults should participate in as much physical activity as their condition allows. Swimming would place the least amount of strain on the hip joints affected by the osteoarthritis, and 15 minutes per day 5 days per week is moderate physical activity that would help maintain joint mobility. The options of bicycling, jogging, and walking at the paces described would be considered vigorous physical activity and would place strain on the client’s hips. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.5: Discuss health promotion in relation to the nursing process.

Question 28 Type: MCSA The adult client is effectively demonstrating concepts of wellness, self-responsibility, and decision making through which of the following actions? 1. Planning a menu that includes large portions of an assortment of foods from each of the food groups. 2. Decreasing the number of cigarettes smoked from 3 packs per day to 1.5 packs per day. 3. Practicing sexual abstinence or using a condom during sexual intercourse. 4. Walking at a pace of 3 to 4.5 mph for 15 minutes 3 times per week. Correct Answer: 3 Rationale 1: Menu planning should include appropriate rather than large portions of food from each of the food groups in order to practice good nutrition as a wellness concept. Rationale 2: Decreasing the number of packs of cigarettes smoked per day from 3 to 1.5 will not significantly lower the health risks of smoking; therefore, this action does not demonstrate the wellness concepts of responsibility and good decision-making skills in regards to health care issues. Rationale 3: Wellness concepts are demonstrated through individuals being responsible and able to make good decisions regarding areas such as nutrition, physical activity, safety issues, stress management, emotional growth and well-being, and health care issues in general. Sexual abstinence or use of a condom during sexual intercourse demonstrates responsibility and good decision-making skills in regards to sexual and reproductive health. Rationale 4: Walking at a pace of 3 to 4.5 mph is considered moderate physical activity; walking this pace for 15 minutes 3 times per week does not meet the CDC recommended 2 hours and 30 minutes per week for moderate physical activity; therefore, this action does not demonstrate the wellness concepts of responsibility and good decision-making skills in regards to health care issues. Global Rationale: Wellness concepts are demonstrated through individuals being responsible and able to make good decisions regarding areas such as nutrition, physical activity, safety issues, stress management, emotional growth and well-being, and health care issues in general. Sexual abstinence or use of a condom during sexual intercourse demonstrates responsibility and good decision-making skills in regards to sexual and reproductive health. Menu planning should include appropriate rather than large portions of food from each of the food groups in order to practice good nutrition. Decreasing the number of packs of cigarettes smoked per day from 3 to 1.5 will not significantly lower the health risks of smoking. Walking at a pace of 3 to 4.5 mph is considered moderate physical activity; walking this pace for 15 minutes three times per week does not meet the CDC recommended 2 hours and 30 minutes per week for moderate physical activity. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.1: Describe the concepts of wellness and health promotion.

Question 29 Type: MCSA Based on the Health Promotion Model, which of the following adult clients is demonstrating an activity-related affect variable for choosing to no longer attend a class on stress-reduction techniques? 1. The client whose family members are nonsupportive of the techniques the client has learned during the class. 2. The client who reflects on the last session of the class and feels that she is not benefitting from the techniques learned. 3. The client who resents that there is a no-smoking policy for participants during the class session. 4. The client who feels that the homework given during class is taking too much time. Correct Answer: 2 Rationale 1: Based on the Health Promotion Model, the client who chooses to stop attending the stress-reduction technique class based on lack of family support is demonstrating the variable of interpersonal influence. Rationale 2: The premise of the Health Promotion Model is that individual characteristics, behaviors, and other variables impact the motivation for an individual to participate in health promoting activities. The client that determines the techniques are not beneficial after reflecting on the last session of the stress-reduction technique class is demonstrating subjective feelings about the activity, which is referred to as an activity-related affect variable. Rationale 3: Based on the Health Promotion Model, the client who chooses to stop attending the stress-reduction technique class based on the resentment felt due to the no-smoking policy represents a situational influence variable. Rationale 4: Based on the Health Promotion Model, the client who chooses to stop attending the stress-reduction technique class based on the time necessary for class homework represents the variable of perceived barriers. Global Rationale: The premise of the Health Promotion Model is that individual characteristics, behaviors, and other variables impact the motivation for an individual to participate in health promoting activities. The client who determines that the techniques are not beneficial after reflecting on the last session of the stress-reduction technique class is demonstrating subjective feelings about the activity, which is referred to as an activity-related affect variable. Quitting the class based on lack of family support refers to the variable on interpersonal influence; the client who quits the course based on resentment of the no-smoking policy represents a situational influence variable; and perceived barriers to action is the variable described by the client who feels the class homework is taking too much time. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3: Discuss perspectives of health promotion for the individual, family, and community.

Question 30 Type: MCMA During the admission assessment of a new client, which of the following factors should alert the nurse to possibility that the client is depressed and further evaluation is necessary? Standard Text: Select all that apply. 1. The client reports a history of rheumatoid arthritis and type 2 diabetes, which are both well controlled. 2. The client has been late for work several times due to oversleeping during the last month. 3. The client reports a family history of depression. 4. The client has had difficulty falling asleep for the last 7 days. 5. The client reports a generalized feeling of muscle aches that have occurred over the last 3 weeks. Correct Answer: 2,3,5 Rationale 1: The client reports a history of rheumatoid arthritis and type 2 diabetes, which are both well controlled. Well-controlled chronic illnesses that cause no impairment in social or work functioning is not an indication of depression. Two or more chronic illnesses with impairment in social or work functioning are one of the series of symptoms that may indicate depression and warrants further evaluation. Rationale 2: The client has been late for work several times due to oversleeping during the last month. Depression is indicated if a client reports a series of symptoms that have persisted for more than 2 weeks and have caused impairment in social and/or work functioning. Fatigue and a disturbance in sleep patterns for 3 weeks may indicate depression and warrants further evaluation of the client. Rationale 3: The client reports a family history of depression. A family history of depression is one factor that can contribute to depression, warranting further evaluation of the client. Rationale 4: The client has had difficulty falling asleep for the last 7 days. A disturbance in sleep patterns for more than 2 weeks is one of the symptoms of depression. This client reports difficulty falling asleep for only 7 days. Rationale 5: The client reports a generalized feeling of muscle aches that have occurred over the last 3 weeks. Depression is indicated if a client reports a series of symptoms that have persisted for more than 2 weeks and have caused impairment in social and/or work functioning. Multiple vague symptoms such as generalized aches are one of the symptoms. This client reports that these symptoms have lasted for 3 weeks; therefore, further evaluation for depression is warranted. Global Rationale: Depression is indicated if a client reports a series of symptoms that have persisted for more than 2 weeks and have caused impairment in social and/or work functioning. Being late for work several times over the last month, a family history of depression, and generalized muscle aches over 3 weeks could indicate depression and warrants further evaluation. Two or more chronic illnesses that cause social or work impairment

are one of the symptoms of depression. This client reports these illnesses are well controlled with no indication of social or work impairment. Difficulty falling asleep for 1 week is not a symptom of depression. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.5: Discuss health promotion in relation to the nursing process.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 3 Question 1 Type: MCMA The nurse is conducting a prenatal class to expectant parents. When one of the couples asks how children grow, the nurse explains that growth and development proceeds in a number of ways. Which of the following descriptions will the nurse use to accurately reflect normal growth and development? Standard Text: Select all that apply. 1. Cephalocaudal direction 2. Simple to complex 3. Distal to proximal direction 4. Generalized response to specific response 5. Anterior to posterior Correct Answer: 1,2,4 Rationale 1: Cephalocaudal direction. Growth and development occurs in a cephalocaudal direction; from head to toe. Rationale 2: Simple to complex. Growth and development proceeds from simple to complex; an infant will reach out for an object before actually being able to grasp the object. Rationale 3: Distal to proximal direction. Growth and development does not proceed from distal to proximal but rather from proximal to distal; i.e., from the center of the body outward. Rationale 4: Generalized response to specific response. Growth and development progresses from general to specific responses; an infant responds to stimuli with the entire body, and older child will respond more specifically, for example, with a smile. Rationale 5: Anterior to posterior. Anterior to posterior does not describe a pattern of normal growth and development. Global Rationale: Growth and development (G and D) occurs in a cephalocaudal direction; from head to toe. G and D proceeds from simple to complex; an infant will reach out for an object before actually being able to grasp the object. G and D progresses from general to specific responses; an infant responds to stimuli with the entire body, and older child will respond more specifically, for example with a smile. G and D does not proceed from distal to proximal but rather from proximal to distal; i.e., from the center of the body outward. Anterior to posterior does not describe a pattern of normal growth and development.

Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.1: Identify the principles of growth and development. Question 2 Type: MCMA The nurse identifies which of the following as environmental factors that can influence the growth and development of an individual? Standard Text: Select all that apply. 1. Nutrition 2. Climate 3. Heredity 4. Culture 5. Religion Correct Answer: 1,2,4 Rationale 1: Nutrition. Nutrition is an environmental factor that can affect the growth and development of an individual. Rationale 2: Climate. Climate is an environmental factor that can affect the growth and development of an individual. Rationale 3: Heredity. Heredity drives the physical attributes of growth and development such as stature, gender, and race. Rationale 4: Culture. Culture is an environmental factor that can affect the growth and development of an individual. Rationale 5: Religion. Religion is an environmental factor that can affect the growth and development of an individual. Global Rationale: Nutrition, climate, culture, and religion are all external, environmental factors that can affect how an individual grows and develops over time. Heredity drives the physical attributes of growth and development such as stature, gender, and race. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.1: Identify the principles of growth and development. Question 3 Type: MCSA The nurse is teaching the parents of a child who is in Piaget’s sensorimotor stage of development. Which statement, made by the parents, indicates to the nurse that they understand the teaching and are working appropriately to help the child accomplish developmental tasks of this stage? 1. "We have started buying more colorful toys." 2. "We play with water toys in the bathtub." 3. “We bought some blocks with numbers." 4. "We have been playing peek-a-boo.” Correct Answer: 4 Rationale 1: Buying more colorful toys fosters visual stimulation as the child experiences physiologic growth and development (nervous system), but does not help the child with cognitive development. Rationale 2: Playing with water toys in the bathtub helps a child to develop motor. not cognitive. skills. Rationale 3: Providing a child with numbered blocks targets motor skill development, not cognitive development. Rationale 4: Playing peek-a-boo helps the infant begin to understand that someone is there even when that person is not visible. Piaget’s theory explores how thinking, reasoning, and language develop (cognitive skills). In the sensorimotor stage (birth to 2 years) the infant progresses from responding primarily through reflexes, to purposeful movement and organized activity. It is during this stage that the infant begins to recognize objects and develop object permanence, the knowledge that objects continue to exist even though they are not seen. Global Rationale: Playing the game “peek-a-boo” helps the child to understand that someone is there even when they are not visible. Piaget’s theory explores how thinking, reasoning, and language develop (cognitive skills). In the sensorimotor stage (birth to 2 years) the child progresses from responding primarily through reflexes, to purposeful movement and organized activity. It is during this stage that the child begins to recognize objects and develop object permanence, the knowledge that objects continue to exist even though they are not seen. Buying more colorful toys fosters visual stimulation as the child experiences physiologic growth and development (nervous system), but does not help the child with cognitive development. Playing with water toys in the bathtub helps a child to develop motor not cognitive skills. Providing a child with numbered blocks targets motor skill development, not cognitive development. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.2: Discuss theories of development.

Question 4 Type: MCSA The nurse is developing a care plan for a pediatric client who is at the age to work on Erickson’s developmental stage 4. Which of the following goals would be most appropriate for the nurse to include which would demonstrate the child is accomplishing the tasks in this stage of development? The child will: 1. Watch peers play team sports. 2. Identify one or two pets that would be fun to care for. 3. Complete school homework and have a passing grade within 1 month. 4. Volunteer to help with one or more community projects each week. Correct Answer: 3 Rationale 1: A child who is observing others playing team sports (not participating) may be afraid to join in for fear of not being an adequate player or team member. This does not demonstrate accomplishment of the task at this developmental level. Rationale 2: Identifying one or two pets to care for would not foster a sense of competency, creativity, and perseverance since mastering this task would require actually caring for the pet or pets. Rationale 3: Erickson identified 8 stages of personality development in which a person must resolve a conflict based on physiologic and societal expectations. During Stage 4 (ages 6–11 years), the crisis of industry versus inferiority presents. Industry results in the development of competency, creativity and perseverance. Inferiority creates feelings of hopelessness, and a sense of being mediocre or incompetent. At this age, school is a major focus in a child’s life; thus reaching a goal of completing school homework and having passing grades within 1 month would help develop a sense of competency and creativity and would also require perseverance in order to be successful. Rationale 4: Volunteering to help with one or more community projects each week is an unrealistic goal for a child of this age. Global Rationale: Erickson identified 8 stages of personality development in which a person must resolve a conflict based on physiologic and societal expectations. During Stage 4 (ages 6–11 years), the child is presented with the crisis of industry versus inferiority. Industry results in the development of competency, creativity and perseverance. Inferiority creates feelings of hopelessness, and a sense of being mediocre or incompetent. At this age, school is a major focus in a child’s life; thus reaching a goal of completing school homework and having passing grades within 1 month would help develop a sense of competency and creativity and would also require perseverance in order to be successful. A child who is observing others playing team sports (not participating) may be afraid to join in for fear of not being an adequate player or team member. This does not demonstrate accomplishment of the task at this developmental level. The crisis of autonomy versus shame and self-doubt presents much earlier at Stage 2 (ages 1–2 years). Identifying one or two pets to care for would not foster a sense of competency, creativity, and perseverance since mastering this task would require actually caring for the pet or

pets. Volunteering to help with one or more community projects each week is an unrealistic goal for a child of this age. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.2: Discuss theories of development. Question 5 Type: MCSA The nurse working at an assisted living facility has just counseled a client experiencing a crisis in Erickson’s developmental stage of integrity versus despair. Which of the following suggestions by the nurse would be most appropriate to assist this client? 1. “You should consider buying a bigger house so that your divorced son can come and live with you.” 2. “You should consider getting a job to fill your time.” 3. “You should organize your family photos into an album” 4. “You should consider playing a sport.” Correct Answer: 3 Rationale 1: During the stage of integrity versus despair an individual reviews life experiences and will either feel contentment and satisfaction with life or feel sadness and a sense of loss. Reviewing life through photos and organizing them into an album may bring a sense of satisfaction to the individual. Rationale 2: Buying a bigger house in order to help an adult child may place a financial burden on an older adult, causing resentment and dissatisfaction with life. Rationale 3: Older adults may have physical limitations related to the normal aging process or health problems that may interfere with their abilities to work. This may actually exacerbate a sense of loss, sadness, and despair. Rationale 4: While older adults are encouraged to remain active, playing sports may be limited in the older adult due to the normal physiologic changes that occur with aging. Global Rationale: During the stage of integrity versus despair an individual reviews life experiences and will either feel contentment and satisfaction with life or feel sadness and a sense of loss. Reviewing life through photos and organizing them into an album may bring a sense of satisfaction to the individual. Buying a bigger house in order to help an adult child may place a financial burden on an older adult, causing resentment and dissatisfaction with life. Older adults may have physical limitations related to the normal aging process or health problems that may interfere with their abilities to work. This may actually exacerbate a sense of loss, sadness, and despair. While older adults are encouraged to remain active, playing sports may be limited in the older adult due to the normal physiologic changes that occur with aging.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.2: Discuss theories of development. Question 6 Type: MCSA The nurse is interviewing the mother of a toddler who verbalizes concerns that her child uses the toilet to void, but refuses to use the toilet for bowel movements, and often hides to defecate. The nurse identifies that this child is in which of the following Freudian phases of psychologic development? 1. Genital 2. Phallic 3. Anal 4. Latency Correct Answer: 3 Rationale 1: The genital phase occurs during puberty through adulthood; the individual experiences sexual urges stimulated by hormonal influences and sexual development. Rationale 2: The phallic phase occurs during years 4 to 6; pleasure is focused on the genital area. Rationale 3: Freud’s anal phase follows the oral phase and continues through age 3. The anus becomes the focus for gratification and the child experiences conflict when expectations about toileting are presented. Rationale 4: The latency phase occurs during years 5 to 6 when energy is focused on intellectual and physical activities and a time to work on unresolved conflicts. Global Rationale: Freud’s anal phase follows the oral phase and continues through age 3. The anus becomes the focus for gratification and the child experiences conflict when expectations about toileting are presented. The genital phase occurs during puberty through adulthood; the individual experiences sexual urges stimulated by hormonal influences and sexual development. The phallic phase occurs during years 4 to 6; pleasure is focused on the genital area. The latency phase occurs during years 5 to 6 when energy is focused on intellectual and physical activities and a time to work on unresolved conflicts. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.2: Discuss theories of development. Question 7

Type: MCMA Using Piaget’s theory of cognitive development, the nurse expects preschoolers will: Standard Text: Select all that apply. 1. Be egocentric and fail to see another's point of view. 2. Focus on many aspects of a given situation at once. 3. Assume everyone else in their world sees things as they do. 4. Believe they have magical powers of thought to control the universe. 5. Understand cause-and-effect relationships Correct Answer: 1,3,4 Rationale 1: Be egocentric and fail to see another's point of view. The preschooler continues to be egocentric and unable to see another's point of view. Rationale 2: Focus on many aspects of a given situation at once. Preschoolers demonstrate centration. That is, they focus on one aspect of a situation and ignore others, leading to illogical reasoning. Rationale 3: Assume everyone else in their world sees things as they do. Preschoolers feel no need to defend their point of view, because they assume that everyone else sees things as they do. Rationale 4: Believe they have magical powers of thought to control the universe. Preschoolers believe their wishes, thoughts, and gestures command the universe. The child believes that these "magical" powers of thought are the cause of all events. Rationale 5: Understand cause-and-effect relationships. Understanding cause-and-effect relationships is developed during the school-age years. Global Rationale: The preschooler continues to be egocentric and unable to see another's point of view. They feel no need to defend their point of view, because they assume that everyone else sees things as they do. Preschoolers demonstrate centration. That is, they focus on one aspect of a situation and ignore others, leading to illogical reasoning. They believe their wishes, thoughts, and gestures command the universe. The child believes that these "magical" powers of thought are the cause of all events. Understanding cause-and-effect relationships is developed during the school-age years. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.2: Discuss theories of development. Question 8 Type: MCSA

A preschool-age child is at play. Which of the following behaviors indicates to the nurse that the child is successfully moving through Piaget’s cognitive stages of development appropriate for this age? 1. The child is able to consider the differing opinions of playmates. 2. The child is able to recall the good time experienced the previous weekend at the playground and is anticipating going there again the following week. 3. The child reports being able to rationalize why it is better to eat fruit than candy. 4. The child understands that his mother loves him as much as she loves the child’s older siblings. Correct Answer: 2 Rationale 1: The ability to consider the points of view of others does not occur until the Concrete Operations stage. Rationale 2: The child is able to recall the good time experienced the previous weekend at the playground and is anticipating going there again the following week. This indicates that Rationale 3: The child is progressing without difficulty in Piaget’s Cognitive Theory. Stage 2: Preoperational Skills encompasses ages 2 to 7 years. Rationale 4: Rational thinking begins around the age of 11 and continues into adulthood. This is the stage known as Formal Operations. Global Rationale: The child is able to recall the good time experienced the previous weekend at the playground and is anticipating going there again the following week. This indicates that the child is progressing without difficulty in Piaget’s Cognitive Theory. Stage 2: Preoperational Skills encompasses ages 2 to 7 years. During this time, the child is able to recall past events and anticipate future events. The ability to consider the points of view of others does not occur until the Concrete Operations stage. Rational thinking begins around the age of 11 and continues into adulthood. This is the stage known as Formal Operations. The issue of maternal love does not impact this question. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.2: Discuss theories of development. Question 9 Type: MCSA An older adult client voices concerns to the nurse regarding the seemingly continued loss of family and friends to illness and death. The client states, “God is cruel. I have no one anymore. I am too old to make new friends; it’s useless, everyone leaves me.” Using Erickson’s psychosocial theory, the nurse interprets the client’s remarks. This client is:

1. Successfully mastering the stage of integrity versus despair. 2. Is having difficulty passing through the stage of generativity versus stagnation. 3. Is experiencing struggles to succeed in the stage of integrity versus despair. 4. Is demonstrating unsuccessful completion of the intimacy versus isolation stage of development. Correct Answer: 3 Rationale 1: During the stage of integrity versus despair (ages 65 to death) the client reflects on life and the inevitability of death. Clients are often faced with the loss of friends and family members. Acceptance of these losses results in successful movement through this stage. Rationale 2: During the stage of generativity versus stagnation (ages 40–65), the client either demonstrates productivity and creativity or begins to become self absorbed and nonproductive. Rationale 3: The client is experiencing struggles to succeed in the stage of integrity versus despair. During this phase, the client reflects on life and the inevitability of death. Clients are often faced with the loss of friends and family members. Failure to accept this stage of life will result in bitterness. Rationale 4: In the phase of intimacy versus isolation (ages 19–40) adults find mates or face a life of loneliness. Global Rationale: The client is experiencing struggles to succeed in the stage of integrity versus despair. During this phase (ages 65 to death), the client reflects on life and the inevitability of death. Clients are often faced with the loss of friends and family members. Acceptance of these losses results in successful movement through this stage. Failure to accept this stage of life will result in bitterness. During the stage of generativity versus stagnation (ages 40–65), the client either demonstrates productivity and creativity or begins to become self-absorbed and nonproductive. In the phase of intimacy versus isolation (ages 19–40) adults find mates or face a life of loneliness. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.2: Discuss theories of development. Question 10 Type: MCSA During a well-baby check the nurse notices the infant does not demonstrate the expected developmental milestones for this age. Which of the following nursing interventions should be completed first? 1. The nurse should initiate a consult with social services for a home assessment. 2. The nurse should consult with the health care provider. 3. The nurse should ask the parents questions about their play activities with the infant.

4. The nurse should prepare the family for a potentially upsetting diagnosis. Correct Answer: 3 Rationale 1: It is outside the nurse’s scope of practice to initiate consults. The healthcare provider will recommend and manage consultations. Rationale 2: The nurse should complete the assessment before consulting with the health care provider. Rationale 3: The nurse should first assess the parental knowledge and expectations concerning normal infant development. The parents may not be aware of the appropriate activities that will stimulate the child. Rationale 4: There is no need to prepare the parents for a negative outcome at this point. Global Rationale: The nurse should first assess the parental knowledge and expectations concerning normal infant development. The parents may not be aware of the appropriate activities that will stimulate the child. It is outside the nurse’s scope of practice to initiate consults. The healthcare provider will recommend and manage consultations. The nurse should complete the assessment before consulting with the health care provider. There is no need to prepare the parents for a negative outcome at this point. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3: Describe stages of development. Question 11 Type: MCSA In preparation for a sport’s physical examination, the nurse is assessing the height of a 16-year-old male client. The client measures 5′5″. The client voices concerns about his lack of stature. He asks if he has reached his full height. Which of the responses by the nurse is most appropriate? 1. “By age 16, you are finished growing.” 2. “Is your father very tall?” 3. “Why do you hope to grow taller?” 4. “You may continue to grow into your early 20s.” Correct Answer: 4 Rationale 1: On average, the fastest rate of growth in adolescent males occurs at about age 14 and continues for 24–30 months. After that time, growth continues but at a slower rate. Rationale 2: Although a child’s height may relate to that of the parents, this statement does not respond to the client’s question.

Rationale 3: Asking the teen about his motivation to grow taller does not respond to his question. Rationale 4: Skeletal growth may continue until age 25, when the epiphyses of the long bones are finally fused. Global Rationale: Skeletal growth may continue until age 25, when the epiphyses of the long bones are finally fused. On average, the fastest rate of growth in adolescent males occurs at about age 14 and continues for 24–30 months. After that time, growth continues but at a slower rate. Although a child’s height may relate to that of the parents, this statement does not respond to the client’s question. Asking the teen about his motivation to grow taller does not respond to his question. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.3: Describe stages of development. Question 12 Type: MCSA During a routine physical examination, a middle-aged female client reports concern about the weight gained over the past 2 years despite not having made any significant changes in diet or exercise patterns. The nurse understands that which of the following factors may be responsible for the client’s reported changes in weight? 1. The client’s increasing hormone levels 2. The client’s increase in body mass index 3. The reduction in muscle nerve conduction 4. The hormonal changes of the female climacteric Correct Answer: 4 Rationale 1: During this client’s stage of development, there is a reduction, not an increase, in hormone levels as menopause (the female climacteric) approaches. Rationale 2: Body mass index is determined by height and weight, but is not responsible for weight changes. Rationale 3: The changes in muscle and nerve development are not directly implicated in the body changes being reported. Rationale 4: Decreased hormone production results in an increase in body weight. The amount of adipose tissue also increases. Global Rationale: During this client’s stage of development, there is a reduction, not an increase, in hormone levels as menopause (the female climacteric) approaches. Decreased hormone production results in an increase in body weight. The amount of adipose tissue also increases. Body mass index is determined by height and weight,

but is not responsible for weight changes. The changes in muscle and nerve development are not directly implicated in the body changes being reported. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3: Describe stages of development. Question 13 Type: MCMA The adult children of an older adult client report they are becoming frustrated. They relate they are trying to get their parent to “take it easy”; stop working and reduce social activities. When questioned by the nurse, they report feeling this lessened stress will protect their loved one. Which of the following statements should be included in the nurses responses? Standard Text: Select all that apply. 1. “Keeping busy will assist your parent to remain productive.” 2. “Older adults who lack intellectual challenges may demonstrate cognitive declines.” 3. “Your plans will increase your parent’s quality of life.” 4. “Retirement will promote rest and relaxation for your parent.” 5. “It is important for older adults to have opportunities to develop and maintain friendships.” Correct Answer: 1,2,5 Rationale 1: “Keeping busy will assist your parent to remain productive.” It is important for older adults to engage in activities that promote a sense of self–worth and usefulness. Rationale 2: “Older adults who lack intellectual challenges may demonstrate cognitive declines.” Studies have shown that seniors who continue to demonstrate intellectual interaction may have higher cognitive function levels. Rationale 3: “Your plans will increase your parent’s quality of life.” While the children of the client believe that “taking it easy” will be protective, a lack of activity is consistent with a decline in function. Rationale 4: “Retirement will promote rest and relaxation for your parent.” Retirement may become more a source of stress than “rest and relaxation” as income is reduced. Lack of financial resources can limit activities and lifestyle. Rationale 5: “It is important for older adults to have opportunities to develop and maintain friendships.” Developing friendships with people of like interests promote the self-worth and usefulness of older adults.

Global Rationale: It is important for older adults to engage in activities that promote a sense of self–worth and usefulness. Studies have shown that seniors who continue to demonstrate intellectual interaction may have higher cognitive function levels. While the children of the client believe that “taking it easy” will be protective, a lack of activity is consistent with a decline in function. Retirement may become more a source of stress than “rest and relaxation” as income is reduced. Lack of financial resources can limit activities and lifestyle. Developing friendships with people of like interests promote the self-worth and usefulness of older adults. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.3: Describe stages of development. Question 14 Type: MCSA Just after an appointment with the health care provider, an older adult client asks the nurse, “Why can’t I seem to exercise like I did when I was younger? I just don’t have the endurance that I did when I was 45, even though I feel good. The health care provider says I’m in good health and can exercise, but do you think there could be something wrong with me?” The nurse’s best response to this client’s statement is: 1. “I think you should discuss this further with the health care provider; maybe you need more tests.” 2. “As individuals get older, there are normal changes that occur in the body, specifically the heart and lungs, that may contribute to decreased endurance. “ 3. “The health care provider cleared you for exercise. I’m sure you are fine.” 4. “The body undergoes physiologic changes that can affect your endurance, such as decreased cardiac output and increased residual air volume in the lungs.” Correct Answer: 2 Rationale 1: The nurse should first answer the client’s question/concern. It may be appropriate to suggest further discussion with the health care provider if the client isn’t satisfied with the nurse’s explanation, but suggesting further testing may lead the client to believe the nurse suspects there is something wrong. Rationale 2: The nurse should explain to the client in simple terms that it is normal in the older years to experience a decrease in endurance due to the physiologic changes that occur with aging. Specifically, the heart becomes stiffer, which affects the pumping action, the valves of the heart become less pliable, leading to decreased filling and emptying, and cardiac output and reserve is decreased. This makes it difficult for the heart to adjust quickly to increased demands. The respiratory system is less efficient. Lungs are stiffer, residual air (space where gas exchange does not occur) is increased, and vital capacity (area where gas exchange does take place) is decreased. The respiratory effort is increased to keep up with oxygen demands. Staying active will help a person build endurance. Rationale 3: Telling the client, “The health care provider cleared you for exercise. I’m sure you are fine,” does not answer the client’s questions or address the concern.

Rationale 4: Responding to the client with “The body undergoes physiologic changes that can affect your endurance, such as decreased cardiac output and increased residual air volume in the lungs,” is a medical explanation that the client may not understand. Global Rationale: The nurse should explain to the client in simple terms that it is normal in the older years to experience a decrease in endurance due to the physiologic changes that occur with aging. Specifically, the heart becomes stiffer, which affects the pumping action, the valves of the heart become less pliable, leading to decreased filling and emptying, and cardiac output and reserve is decreased. This makes it difficult for the heart to adjust quickly to increased demands. The respiratory system is less efficient. Lungs are stiffer, residual air (space where gas exchange does not occur) is increased, and vital capacity (area where gas exchange does take place) is decreased. The respiratory effort is increased to keep up with oxygen demands. Staying active will help a person build endurance. The nurse should first answer the client’s question/concern. It may be appropriate to suggest further discussion with the health care provider if the client isn’t satisfied with the nurse’s explanation, but suggesting further testing may lead the client to believe the nurse suspects there is something wrong. Telling the client, “The health care provider cleared you for exercise. I’m sure you are fine,” does not answer the client’s questions or address the concern. Responding to the client with “The body undergoes physiologic changes that can affect your endurance, such as decreased cardiac output and increased residual air volume in the lungs,” is a medical explanation that the client may not understand. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.3: Describe stages of development. Question 15 Type: MCSA The nurse is talking with an older adult client who has recently retired after 45 years of working as an executive at the same company. Which of the following demonstrates to the nurse that the client is adjusting to this new phase of life? 1. The client spends most of the day at home and declines invitations to outside gatherings with friends because there is “so much to do” at home. 2. The client has enrolled in courses at the local university to complete the college degree that was started “years ago,” but interrupted by family responsibilities. 3. The client has lunch at the company cafeteria several times each week. 4. The client has purchased hearing aids, but rarely uses them. Correct Answer: 2 Rationale 1: Enrolling in college courses is an activity that can be very fulfilling in the older adult years, especially after retirement when there is more time to pursue interests. This can provide a stimulating environment intellectually and socially, as well as give a person a sense of self-worth and accomplishment.

Rationale 2: Spending the day at home and declining outside invitations may be a sign that the client is not adjusting well to retirement. Rationale 3: Eating lunch at the company cafeteria several times a week does not demonstrate a healthy adjustment to retirement. Rationale 4: Refusing to wear hearing aids may indicate that the client is not adjusting to the physical changes of the older adult years. Global Rationale: Enrolling in college courses is an activity that can be very fulfilling in the older adult years, especially after retirement when there is more time to pursue interests. This can provide a stimulating environment intellectually and socially, as well as give a person a sense of self-worth and accomplishment. Spending the day at home and declining outside invitations may be a sign that the client is not adjusting well to retirement. Eating lunch at the company cafeteria several times a week does not demonstrate a healthy adjustment to retirement. Refusing to wear hearing aids may indicate that the client is not adjusting to the physical changes of the older adult years. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.3: Describe stages of development. Question 16 Type: MCSA An older adult presents to the clinic for a routine physical examination. The client reports having trouble with memory and often has to “search” for words when having a conversation with friends or family. Which of the following assessment tools will help the nurse to gather more data about this client’s concerns? 1. The Denver II 2. Mini-Mental Status Examination 3. Life Experiences Survey 4. Hassles and Uplifts Scale Correct Answer: 2 Rationale 1: The Denver II is a screening tool used to assess personal-social, fine motor adaptive, language, and gross motor skills in children between birth and 6 years of age. Rationale 2: The nurse should use the Mini-Mental Status Examination to gather more information about the cognitive status of this client. This tool is also useful to estimate cognitive impairment as well as to track cognitive changes over time.

Rationale 3: The Life Experiences Survey is used to evaluate the level of stress an individual is experiencing; this is not appropriate for this client’s concerns. Rationale 4: The Hassles and Uplifts Scale measures attitudes about daily situations; it does not screen for cognitive changes. Global Rationale: The nurse should use the Mini-Mental Status Examination to gather more information about the cognitive status of this client. This tool is also useful to estimate cognitive impairment as well as to track cognitive changes over time. The Denver II is a screening tool used to assess personal-social, fine motor adaptive, language, and gross motor skills in children between birth and 6 years of age. The Life Experiences Survey is used to evaluate the level of stress an individual is experiencing; this is not appropriate for this client’s concerns. The Hassles and Uplifts Scale measures attitudes about daily situations; it does not screen for cognitive changes. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4: Identify a variety of measurements of growth and development across the age span. Question 17 Type: MCSA During a well-baby visit, the nurse measures the height and weight of an infant and plots the measurements on the baby’s growth chart. The nurse notes a slowed growth pattern. Which of the following would be an appropriate action for the nurse to take? 1. Obtain an endocrinologist referral. 2. Perform a nutritional assessment. 3. Wait until the next visit to intervene. 4. Assess for circulatory problems. Correct Answer: 2 Rationale 1: Referring the baby to an endocrinologist would be done by the health care provider, not the nurse, as this is outside the nurse’s scope of practice. Rationale 2: The nurse should perform a nutritional assessment because slowed growth is an early indicator of inadequate nutrition. It is expected that the rate of growth will remain consistent throughout infancy. Rationale 3: The nurse should not wait until the next visit to intervene as early intervention, which commonly involves parent education and support, can often resolve problems. Rationale 4: Before looking for other causes of slowed growth, the nurse should first assess the baby’s nutritional status. Assessing for circulatory problems might follow if adequate nutrition has already been established.

Global Rationale: The nurse should perform a nutritional assessment because slowed growth is an early indicator of inadequate nutrition. It is expected that the rate of growth will remain consistent throughout infancy. Referring the baby to an endocrinologist would be done by the health care provider, not the nurse, as this is outside the nurse’s scope of practice. The nurse should not wait until the next visit to intervene as early intervention, which commonly involves parent education and support, can often resolve problems. Before looking for other causes of slowed growth, the nurse should first assess the baby’s nutritional status. Assessing for circulatory problems might follow if adequate nutrition has already been established. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4: Identify a variety of measurements of growth and development across the age span. Question 18 Type: MCSA The parent of a 3-year-old child voices concerns about the child’s potential developmental delays. The parent reports an older child reached milestones significantly ahead of the younger child. An assessment reveals the child is able to assist with dressing and can play catch. Which of the following responses by the nurse is appropriate? 1. “Your child appears to be on target with the expected milestones for age.” 2. “Your older child may simply be smarter than your 3 year old.” 3. “I would recommend extensive testing to determine the source of the delays.” 4. “Have you spoken with the health care provider about these delays?” Correct Answer: 1 Rationale 1: The developmental tasks of the child are on track for age. Rationale 2: Advising the parent one child is “smarter” than another is potentially damaging as well as inappropriate. Rationale 3: Testing is not warranted at this time, the child is within the norms of development. Rationale 4: There are not evident delays to review with the healthcare provider. Global Rationale: The developmental tasks of the child are on track for age. Advising the parent one child is “smarter” than another is potentially damaging as well as inappropriate. Testing is not warranted at this time, the child is within the norms of development. There are not evident delays to review with the healthcare provider. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3.4: Identify a variety of measurements of growth and development across the age span. Question 19 Type: MCMA When reviewing the developmental behaviors of an 8-month-old infant, which of the following behaviors indicates to the nurse the need for follow-up assessments? Standard Text: Select all that apply. 1. Unable to sit for brief periods of time without support 2. Moro reflex present 3. Crawling on abdomen 4. Pulls self to standing position 5. Positive Babinski reflex Correct Answer: 1,2 Rationale 1: Unable to sit for brief periods of time without support. By the age of 8 months the child should be able to sit for brief periods without support. Some children can sit alone well at this age. The child who is unable to sit for short periods alone needs further testing and evaluation. Rationale 2: Moro reflex present. The Moro (startle) reflex should disappear between the ages of 4–6 months. The presence of this reflex beyond that age warrants follow-up. Rationale 3: Crawling on abdomen. Around 6 months of age, infants begin to crawl on their abdomens, so it is expected that an 8-month-old will do this. Rationale 4: Pulls self to standing position. Some 8-month-old babies may also be able to pull themselves up to a standing position. This is more typical of a 9-month-old. Rationale 5: Positive Babinski reflex. The Babinski reflex doesn’t begin to fade until 12 months, and is absent by the age of 2 years. Global Rationale: By the age of 8 months the child should be able to sit for brief periods without support. Some children can sit alone well at this age. The child who is unable to sit for short periods alone needs further testing and evaluation. The Moro (startle) reflex should disappear between the ages of 4–6 months. The presence of this reflex beyond that age warrants follow-up. Around 6 months of age, infants begin to crawl on their abdomens, so it is expected that an 8-month-old will do this. Some 8-month-old babies may also be able to pull themselves up to a standing position. This is more typical of a 9-month-old. The Babinski reflex doesn’t begin to fade until 12 months, and is absent by the age of 2 years. Cognitive Level: Applying Client Need: Health Promotion and Maintenance

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4: Identify a variety of measurements of growth and development across the age span. Question 20 Type: MCSA The mother of a toddler tells the nurse that she is concerned about her child’s lower back curving in and the child’s belly sticking out. Which of the following actions would be appropriate for the nurse? 1. Suggest that the mother to buy the child bigger clothes. 2. Give the mother the first available appointment to see the health care provider. 3. Contact the health care provider to see if an orthopedic referral is necessary. 4. Reassure the mother that this is normal for a toddler. Correct Answer: 4 Rationale 1: Suggesting that the mother buy her child larger clothes does not address her concern that there is something abnormal with her child. Rationale 2: The mother is describing a normal finding in a toddler; therefore a visit with the health care provider is not needed. Rationale 3: There is no need for the nurse to consult with the health care provider or consider orthopedic referral since this is a normal finding in a toddler. Rationale 4: The mother is describing toddler lordosis (a curving in of the lower back, which produces a potbelly). This is a normal finding in this age group and resolves as the abdominal muscles develop and pull the abdomen in. Global Rationale: Young toddlers have pronounced lordosis, which makes their abdomens protrude. This is a normal finding, and the mother should be reassured of this. Suggesting that the mother buy her child larger clothes does not address her concern that there is something abnormal with her child. The mother is describing a normal finding in a toddler; therefore a visit with the health care provider is not needed. There is no need for the nurse to consult with the health care provider or consider orthopedic referral since this is a normal finding in a toddler. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.5: Discuss growth and development in relation to health assessment. Question 21 Type: MCSA

The mother of a 5-month-old infant calls the pediatrician's office to report to the nurse that she has noticed that her infant still has tremors of the extremities and chin at times. Which of the following actions would be appropriate for the nurse? 1. Reassure the mother that these tremors are a normal part of the infant’s development. 2. Give the mother the first available appointment to see the health care provider. 3. Contact the health care provider to see if an electroencephalogram (EEG) should be ordered. 4. Ask the mother to keep a diary of the tremors and schedule an appointment for next week. Correct Answer: 1 Rationale 1: Tremors of the extremities or chin of an infant are normal and reflect immature myelinization. This will disappear by 1 year of age as the nervous system continues to develop and myelinization of the efferent pathways matures. Rationale 2: It is not necessary for the infant to be seen on an urgent basis; this is a normal phase of development. Rationale 3: It is not necessary to consult the health care provider to discuss possible EEG as this is not indicative of seizure activity, but rather the result of an immature but normal nervous system. Rationale 4: It is not necessary for the mother to record these tremors or see the health care provider since this is normal for a child of this age. Global Rationale: Tremors of the extremities or chin of an infant are normal and reflect immature myelinization. This will disappear by 1 year of age as the nervous system continues to develop and myelinization of the efferent pathways matures. It is not necessary for the infant to be seen on an urgent basis; this is a normal phase of development. It is not necessary to consult the health care provider to discuss possible EEG as this is not indicative of seizure activity, but rather the result of an immature but normal nervous system. It is not necessary for the mother to record these tremors or see the health care provider since this is normal for a child of this age. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.5: Discuss growth and development in relation to health assessment. Question 22 Type: MCSA The father of a preschool-aged child tells the nurse he is concerned that his son cannot ride a tricycle. Which of the following actions would be appropriate for the nurse? 1. Reassure the father that this is normal. 2. Refer the child to the health care provider.

3. Perform further growth and development assessments. 4. Ask the father about any siblings and at what age they rode a tricycle. Correct Answer: 3 Rationale 1: While the child may not be developmentally delayed, simply reassuring the father that this is normal without further assessment is not an appropriate action by the nurse. Rationale 2: By first performing further growth and developmental assessments the nurse is better informed as to the need and urgency of a referral to the health care provider. Rationale 3: The nurse should perform further growth and development assessments as gross and fine motor development undergo rapid development during the toddler years (ages 1–3). A preschool aged child (ages 3–5) should be able to pedal a tricycle, a major accomplishment typically mastered at the end of the toddler years. Rationale 4: Before gathering information about other children in the family and their developmental milestones, this child should be thoroughly assessed. Global Rationale: The nurse should perform further growth and development assessments as gross and fine motor development undergo rapid development during the toddler years (ages 1–3). A preschool aged child (ages 3–5) should be able to pedal a tricycle, a major accomplishment typically mastered at the end of the toddler years. While the child may not be developmentally delayed, simply reassuring the father that this is normal without further assessment is not an appropriate action by the nurse. By first performing further growth and developmental assessments the nurse is better informed as to the need and urgency of a referral to the health care provider. Before gathering information about other children in the family and their developmental milestones, this child should be thoroughly assessed. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.5: Discuss growth and development in relation to health assessment. Question 23 Type: MCSA The nurse is counseling the parents of a young teenager who is experiencing behavioral problems. The nurse would correctly choose which of the following assessment tools in this situation? 1. Family Psychosocial Screening 2. Eyeburg Child Behavior Inventory 3. Ages and Stages Questionnaire 4. Child Development Inventory

Correct Answer: 2 Rationale 1: The Family Psychosocial Screening is a tool that helps to identify psychosocial risk factors associated with developmental problems, such as parental history of physical abuse as a child, parental substance abuse, and maternal depression. Rationale 2: The Eyeburg Child Behavior Inventory is a parent report scale of conduct problems in children ages 2 to 16 and would be the best choice for the nurse in this situation. Rationale 3: The Ages and Stages Questionnaire is a tool that covers developmental areas of communication, gross and fine motor, and problem solving, not behavior. Rationale 4: The Child Development Inventory is used to measure development in children between the ages of 15 months to 6 years and is not appropriate for a young teenager. Global Rationale: The Eyeburg Child Behavior Inventory is a parent report scale of conduct problems in children ages 2 to 16 and would be the best choice for the nurse in this situation. The Family Psychosocial Screening is a tool that helps to identify psychosocial risk factors associated with developmental problems, such as parental history of physical abuse as a child, parental substance abuse, and maternal depression. The Ages and Stages Questionnaire is a tool that covers developmental areas of communication, gross and fine motor, and problem solving, not behavior. The Child Development Inventory is used to measure development in children between the ages of 15 months to 6 years and is not appropriate for a young teenager. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.5: Discuss growth and development in relation to health assessment. Question 24 Type: MCMA The nurse is caring for a young adult client in the clinic who presents for a routine health examination. The nurse anticipates which of the following interventions for this client? Standard Text: Select all that apply. 1. Counseling on injury prevention 2. Tetanus/diphtheria vaccination booster 3. Counseling on fluoride supplements 4. Information on diet and exercise 5. Fecal occult blood test Correct Answer: 1,2,3,4

Rationale 1: Counseling on injury prevention. Counseling on injury prevention is part of the periodic health exam of the young adult. Rationale 2: Tetanus/diphtheria vaccination booster. Young adults should receive a Td booster if it has been > 10 years since the last booster. Rationale 3: Counseling on fluoride supplements. Counseling on the use of fluoride toothpaste to deter tooth decay is included in the periodic health exam of the young adult. Rationale 4: Information on diet and exercise. Information on diet and exercise is part of the periodic health exam of the young adult. Rationale 5: Fecal occult blood test. Fecal occult blood testing is not routinely done until adults reach middle age (> 50 years of age). Global Rationale: Interventions for periodic health examinations for young adults include counseling on injury prevention, counseling on dental health and the regular use of a toothpaste containing fluoride, counseling on recommended immunizations, which include tetanus/diphtheria booster (Td) if none in the past 10 years, and information on diet and exercise. Fecal occult blood testing is not routinely done until adults reach middle age (> 50 years of age). Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.5: Discuss growth and development in relation to health assessment. Question 25 Type: MCMA Which of the following assessment findings in an older adult client does the nurse associate with the normal aging process? Standard Text: Select all that apply. 1. Increased systolic blood pressure 2. Increased muscle tone 3. Decreased cardiac output 4. Increased vital capacity 5. Decreased renal function Correct Answer: 1,3,5

Rationale 1: Increased systolic blood pressure. Systolic blood pressure increases due to a decrease in the elasticity of the arteries and increased peripheral vascular resistance. Rationale 2: Increased muscle tone. Muscle tone is decreased. Rationale 3: Decreased cardiac output. Cardiac output is diminished due to alteration in pumping action as the heart muscle thickens. Rationale 4: Increased vital capacity. Respiratory vital capacity is decreased as the lungs become stiffer and less efficient. Rationale 5: Decreased renal function. Renal function decreases as blood flow to the kidneys is affected by arteriosclerotic changes and a decrease in the number of nephrons. Global Rationale: The older adult experiences a normal decline in body function. Systolic blood pressure increases due to a decrease in the elasticity of the arteries and increased peripheral vascular resistance. Cardiac output is diminished due to alteration in pumping action, as the heart muscle thickens. Renal function decreases as blood flow to the kidneys is affected by arteriosclerotic changes and a decrease in the number of nephrons. Respiratory vital capacity is decreased as the lungs become stiffer and less efficient. Muscle tone is decreased. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.5: Discuss growth and development in relation to health assessment. Question 26 Type: MCSA The nurse is counseling a middle-aged couple when the man asks if his wife is going through menopause. His wife has told him that both men and women experience decreasing hormonal production during middle adulthood, and he asks the nurse if this is true. What is the most appropriate response by the nurse? 1. “Your wife has obtained some incorrect data.” 2. “Why do you ask?” 3. “Your hormonal levels increase, not decrease with age.” 4. “Your wife is correct. Both men and women experience a decrease in hormone production with aging.” Correct Answer: 4 Rationale 1: The statement by the nurse, “Your wife is correct, both men and women experience a decrease in hormone production with aging” accurately describes changes that take place in the middle-age years.

Rationale 2: Responding by asking another question such as “Why do you ask?” does not answer the initial question asked by the husband of the couple. It is most appropriate for the nurse to answer the husband’s question first and later explore his concerns. Rationale 3: Hormone levels in men and women do not increase with aging. Rationale 4: The statement by the nurse, “Your wife is correct, both men and women experience a decrease in hormone production with aging” accurately describes changes that take place in the middle-age years. During menopause, which usually occurs between ages 40 and 55, the ovaries decrease in size, and the uterus becomes smaller and firmer. Progesterone is not produced and estrogen levels fall. Men also have a decrease in hormonal production and experience a gradual decrease in testosterone. Global Rationale: The statement by the nurse, “Your wife is correct, both men and women experience a decrease in hormone production with aging” accurately describes changes that take place in the middle-age years. During menopause, which usually occurs between ages 40 and 55, the ovaries decrease in size, and the uterus becomes smaller and firmer. Progesterone is not produced and estrogen levels fall. Men also have a decrease in hormonal production and experience a gradual decrease in testosterone. Hormone levels in men and women do not increase with aging. Responding by asking another question such as “Why do you ask?” does not answer the initial question asked by the husband of the couple. It is most appropriate for the nurse to answer the husband’s question first and later explore his concerns. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.6: Discuss factors that influence growth and development. Question 27 Type: MCSA An infant has been admitted to the pediatric unit for observation. The admission assessment indicates the family is Cuban American. When assessing the family’s interactions the nurse notes the mother does all the care of the child while the father seems detached from the infant. Which of the following would be the most appropriate nursing diagnosis in this situation? 1. Compromised family coping 2. Altered role functions 3. Risk for family violence 4. Readiness for enhanced family processes Correct Answer: 4 Rationale 1: The family is operating and coping within the norm of its Cuban American culture; therefore, compromised family coping is not an appropriate nursing diagnosis for this infant and family.

Rationale 2: The role functions of the parents are not altered and are culturally appropriate with the mother being the infant’s primary caretaker. Rationale 3: The nurse must be cognizant of a client’s cultural norms in order to accurately make assessments and determine real or potential problems. There is nothing to suggest a risk for family violence. Rationale 4: The readiness for enhanced family processes is by definition a pattern of family functioning that is sufficient to support the well-being of family members and can be strengthened. Paternal and maternal attachment differs among cultures. In the Cuban American culture, the mother is the primary caregiver and bonds with the child earlier and continually, while the father remains detached from infant care and begins attachment behaviors only when the child is able to walk and communicate. Global Rationale: The readiness for enhanced family processes is by definition a pattern of family functioning that is sufficient to support the well-being of family members and can be strengthened. Paternal and maternal attachment differs among cultures. In the Cuban American culture, the mother is the primary caregiver and bonds with the child earlier and continually, while the father remains detached from infant care and begins attachment behaviors only when the child is able to walk and communicate. The family is operating and coping within the norm of its Cuban American culture; therefore, compromised family coping is not an appropriate nursing diagnosis for this infant and family. The role functions of the parents are not altered and are culturally appropriate with the mother being the infant’s primary caretaker. And finally, the nurse must be cognizant of a client’s cultural norms in order to accurately make assessments and determine real or potential problems. There is nothing to suggest a risk for family violence. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3.6: Discuss factors that influence growth and development. Question 28 Type: MCSA The nurse is completing discharge teaching to the family of a hospitalized older adult client. Which of the following is most important for the nurse to include in this teaching plan? 1. Reducing the amount of odor in the client's immediate environment 2. Protecting the client from injury due to increased pain threshold 3. Speaking in an increasingly loud voice as client's hearing decreases 4. Avoiding range of motion exercises due to loss of bone density and increased risk for fracture Correct Answer: 2 Rationale 1: The sense of smell decreases with age; reducing the amount of odor in the client’s immediate environment is not a priority.

Rationale 2: Protecting the client from injury is the most important teaching point. In the older adult, there is an increased threshold for the sensation of pain and touch as well as a decrease in reaction time. Rationale 3: Older adults experience a gradual loss of hearing; speaking at a level that the client can hear is important, but not above protection from injury. Rationale 4: Range of motion should be encouraged to facilitate mobility and is not a risk factor for fractures. Global Rationale: Protecting the client from injury is the most important teaching point. In the older adult, there is an increased threshold for the sensation of pain and touch as well as a decrease in reaction time. The sense of smell decreases with age; reducing the amount of odor in the client’s immediate environment is not a priority. Older adults experience a gradual loss of hearing; speaking at a level that the client can hear is important, but not above protection from injury. Range of motion should be encouraged to facilitate mobility and is not a risk factor for fractures. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.6: Discuss factors that influence growth and development. Question 29 Type: MCSA The nurse is caring for a hospitalized infant. When the infant begins to cry, the parents report they do not believe in responding too rapidly, as they do not wish to spoil their child. Which of the following responses by the nurse is most appropriate? 1. “I agree with your philosophy of child rearing.” 2. “There are many studies that support this belief.” 3. “Responding quickly to your baby’s cries will assist the baby in feeling secure and does not result in a spoiled child.” 4. “Children who experience separation anxiety have been spoiled by their parents.” Correct Answer: 3 Rationale 1: The nurse should not be offering personal beliefs or philosophies to clients or their families. Rationale 2: Concern over “spoiling” infants by promptly responding to their cries is no longer an accepted concept. Research has shown that infants whose mothers respond promptly to their cries during the early months of life cry less at 1 year of age. Rationale 3: A timely response to infant crying does not result in a spoiled child. It promotes the infant’s sense of security and promotes independence during later stages of development.

Rationale 4: Children who have received inconsistent nurturing may experience clingy, angry, or distrustful behaviors. Global Rationale: A timely response to infant crying does not result in a spoiled child. It promotes the infant’s sense of security and promotes independence during later stages of development. The nurse should not be offering personal beliefs or philosophies to clients or their families. Concern over “spoiling” infants by promptly responding to their cries is no longer an accepted concept. Research has shown that infants whose mothers respond promptly to their cries during the early months of life cry less at 1 year of age. Children who have received inconsistent nurturing may experience clingy, angry, or distrustful behaviors. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.6: Discuss factors that influence growth and development. Question 30 Type: MCSA The nurse is explaining the influence of culture on growth and development to a group of expectant first-time parents. The nurse recognizes the need for further teaching when a parent states: 1. “Mothers and fathers should always share in the responsibilities of caring for a new baby.” 2. “Culture may influence the rate at which developmental milestones occur.” 3. “The ways in which children are disciplined may vary among cultures.” 4. “The value of education varies among cultures.” Correct Answer: 1 Rationale 1: Family roles differ among cultures. While it is customary among Caucasian parents to bond with the infant early in the neonatal period, it is the mother who bonds with the infant in the Cuban American culture. Rationale 2: Developmental milestones can be affected by culture; for example, African American toddlers have been found to develop some motor skills earlier than Caucasian toddlers. Rationale 3: The discipline of children varies among cultures. Rationale 4: The value of education varies among cultures. Global Rationale: Family roles differ among cultures. While it is customary among Caucasian parents to bond with the infant early in the neonatal period, it is the mother who bonds with the infant in the Cuban American culture. Developmental milestones can be affected by culture; for example, African American toddlers have been found to develop some motor skills earlier than Caucasian toddlers. The discipline of children varies among cultures. The value of education varies among cultures.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.6: Discuss factors that influence growth and development.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 4 Question 1 Type: MCSA The nurse is preparing an educational program for the staff on cultural considerations. The nurse includes the following definition: “The adoption and incorporation of characteristics, customs, and values of the dominant culture by those new to that culture.” The nurse is referring to which of the following terms? 1. Ethnicity 2. Assimilation 3. Ethnocentrism 4. Culture Correct Answer: 2 Rationale 1: Ethnicity is the awareness of belonging to a group in which certain characteristics or aspects of a culture, such as biology, differentiate the members of one group from another. Rationale 2: Assimilation matches the definition described. Rationale 3: Ethnocentrism is the tendency to believe that one’s own beliefs, way of life, values, and customs are superior to those of others. Rationale 4: Culture is the nonphysical traits, such as values, beliefs, attitudes, and customs that are shared by a group of people and passed from one generation to another. Global Rationale: Assimilation matches the definition described. Ethnicity is the awareness of belonging to a group in which certain characteristics or aspects of a culture, such as biology, differentiate the members of one group from another. Ethnocentrism is the tendency to believe that one’s own beliefs, way of life, values, and customs are superior to those of others. Culture is the nonphysical traits, such as values, beliefs, attitudes, and customs that are shared by a group of people and passed from one generation to another. Cognitive Level: Remembering Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.1: Define culture. Question 2 Type: MCSA

The nurse is admitting a client of the Muslim faith during the holy month of Ramadan. The client tells the nurse that he must fast during this time. Which of the following would be an appropriate response by the nurse? 1. “What can we do to accommodate your needs during your stay here?” 2. “I will let your doctor know so he can discharge you.” 3. “Fasting is harmful to your body.” 4. “You must have food during times of illness.” Correct Answer: 1 Rationale 1: Some people will report adhering to a particular faith but will not strictly adhere to certain practices. Further assessment is needed to determine this client’s beliefs, desire to adhere to the practice, and extent to which the practice may be altered considering the illness and hospitalization. Making certain assumptions without further assessment would result in actions not respectful of or beneficial to the client. Rationale 2: Making assumptions such as the healthcare provider discharging this client without further assessment would result in actions not respectful of or beneficial to the client. Rationale 3: Making assumptions such as fasting being bad for the body without further assessment would result in actions not respectful of or beneficial to the client. Rationale 4: Making assumptions such as the client being unable to fast during illness without further assessment would result in actions not respectful of or beneficial to the client. Global Rationale: Many faiths describe circumstances in which fasts may be altered or eliminated during times of illness and hospitalization. Additionally, some people will report adhering to a particular faith but will not strictly adhere to certain practices. Further assessment is needed to determine this client’s beliefs, desire to adhere to the practice, and extent to which the practice may be altered considering the illness and hospitalization. Making certain assumptions without further assessment would result in actions not respectful of or beneficial to the client. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 3 Type: MCSA The nurse is caring for an elderly Native American client who is experiencing severe chest pain. A tribesman has accompanied him to the hospital at the insistence of the client. The tribesman tells the nurse that their culture teaches acceptance of death as part of the natural cycle of life and that treatments must be stopped. The client’s son insists that his father be treated, and states he feels the tribe’s teachings are antiquated. What is the best action for the nurse to take in this situation?

1. Call the social worker to plan a family meeting without the tribesman. 2. Interview the client and ascertain his wishes and beliefs. 3. Convene the hospital ethics committee. 4. Call the nursing supervisor. Correct Answer: 2 Rationale 1: It would be inappropriate to call a family meeting, with or without an interested second party, if the client is competent and has not asked for such a meeting. Rationale 2: The client is an adult and, if capable of expressing his wishes and beliefs, should be encouraged to do so. Sometimes the client must be interviewed alone to be sure the client is actually stating his own wishes and not those of family members who may be present for the interview. Unless an adult is not competent to make and express his own decisions, or is impaired in some way and cannot express his own wishes, then the adult client’s wishes are honored over all others who may try to exert influence. Rationale 3: At this time, there is not enough data to ask the hospital ethics committee to render an opinion. Rationale 4: There is at the moment no behavior exhibited that would warrant notifying hospital administration. Global Rationale: The client is an adult and if capable of expressing his wishes and beliefs, should be encouraged to do so. Sometimes the client must be interviewed alone to be sure the client is actually stating his own wishes and not those of family members who may be present for the interview. Unless an adult is not competent to make and express his own decisions, or is impaired in some way and cannot express his own wishes, then the adult client’s wishes are honored over all others who may try to exert influence. It would be inappropriate to call a family meeting, with or without an interested second party, if the client is competent and has not asked for such a meeting. There is at the moment no behavior exhibited that would warrant notifying hospital administration, nor is there enough data to ask the hospital ethics committee to render an opinion. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.4: Explain personal strategies that the nurse can use to develop cultural competence when assessing clients from specific cultural groups. Question 4 Type: MCSA The nurse is assessing a 16-year-old male. The individual is fluent in English, participates in high school sports, values riding his dirt bike, and plans to go to college after graduating from high school. The client’s health history indicates the he was born in China and came to the United States at age 4. When asked where he is from, he says “the United States.” The nurse understands that his behaviors and statements indicate that: 1. He has no interest in the interview.

2. He is embarrassed about his ethnicity. 3. He is assimilated into the American culture. 4. He wishes to deny his Asian heritage. Correct Answer: 3 Rationale 1: There is no evidence that this client is bored with the interview. Rationale 2: There is no evidence that this client is embarrassed. Rationale 3: The teen’s answers indicate characteristics and behaviors of the American culture. Rationale 4: There is no evidence that this client wishes to deny Asian heritage. Global Rationale: The teen’s answers indicate characteristics and behaviors of the American culture. Often, those who have not assimilated are not fluent in the language of the new culture and do not display certain behaviors and characteristics of the new culture. There is no evidence to support other assumptions, such as that he wishes to deny his heritage, that he is embarrassed about his appearance, or that he is bored with the interview. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 5 Type: MCMA The nurse manager is discussing cultural considerations with a group of student nurses. Which of the statements by the nursing students indicates a lack of understanding about cultural concepts? Standard Text: Select all that apply. 1. “Culture can best be described as an awareness of belonging to a group in which certain characteristics differentiate the members of one group from another.” 2. “A good description of culture is one that recognizes it’s the socially transmitted beliefs, behaviors, values, customs, lifestyles and ways of thinking of a specific population that guides an individual’s worldview.” 3. “Culture is the belief that one’s own beliefs, way of life, values, and customs are superior to others.” 4. “Culture is the identification of an individual or group by shared genetic heritage and biologic characteristics.” 5. “Decisions made by an individual are largely influenced by culture.” Correct Answer: 3,4

Rationale 1: “Culture can best be described as an awareness of belonging to a group in which certain characteristics differentiate the members of one group from another.” Ethnicity is the awareness of belonging to a group in which certain characteristics differentiate the members of one group from another. Rationale 2: “A good description of culture is one that recognizes it’s the socially transmitted beliefs, behaviors, values, customs, lifestyles and ways of thinking of a specific population that guides an individual’s worldview.” Culture is the socially transmitted beliefs, behaviors, values, customs, lifestyles, and ways of thinking of a specific population that guides worldview and decision-making. Rationale 3: “Culture is the belief that one’s own beliefs, way of life, values, and customs are superior to others.” Ethnocentrism is the tendency to believe that one’s own beliefs, way of life, values, and customs are superior to others. Rationale 4: “Culture is the identification of an individual or group by shared genetic heritage and biologic characteristics.” Race is the identification of an individual or group by shared genetic heritage and biologic or physical characteristics. Rationale 5: “Decisions made by an individual are largely influenced by culture.” Decision making is guided by one’s beliefs, values, customs and way of thinking, which is culture. Global Rationale: Ethnicity is the awareness of belonging to a group in which certain characteristics differentiate the members of one group from another. Culture is the socially transmitted beliefs, behaviors, values, customs, lifestyles, and ways of thinking of a specific population that guides worldview and decision making. Ethnocentrism is the tendency to believe that one’s own beliefs, way of life, values, and customs are superior to others. Race is the identification of an individual or group by shared genetic heritage and biologic or physical characteristics. Decision making is guided by one’s beliefs, values, customs and way of thinking, which is culture. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.1: Define culture. Question 6 Type: MCSA The nurse is completing a self-assessment to determine cultural competence. The nurse would identify which of the following behaviors as part of being culturally competent? 1. Obtaining a ham sandwich for a Jewish client admitted to the hospital unit after trays have been delivered 2. Referring to the Asian client as an Oriental 3. Permitting a Bedouin to sleep on the floor 4. Advising a Catholic client that being taken to the chapel for noon Mass is impossible because lunch times have been assigned

Correct Answer: 3 Rationale 1: Jewish persons do not eat pork. Rationale 2: Referring to an Asian as an “Oriental” is offensive. Rationale 3: Bedouin immigrants from Arabia are nomads who are used to sleeping on the ground. Rationale 4: Attending Mass is an obligation of Catholics and takes priority over lunchtime assignments, which can be revised. Global Rationale: Bedouin immigrants from Arabia are nomads who are used to sleeping on the ground. Attending Mass is an obligation of Catholics and takes priority over lunchtime assignments, which can be revised. Jewish persons do not eat pork. Referring to an Asian as an “Oriental” is offensive. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.2: Identify terms related to culture. Question 7 Type: MCMA The nurse is studying matriarchal cultures and needs to complete a report on how this aspect affects health care within the culture. The nurse identifies which of the following groups as most likely to be patriarchal? Standard Text: Select all that apply. 1. Appalachian 2. American Indian 3. African American 4. Italian 5. Arab American Correct Answer: 1,4,5 Rationale 1: Appalachian. Patriarchal groups are those that are largely headed by a male family figure. Appalachian families are most likely to be patriarchal. Rationale 2: American Indian. Native American cultures are matrilineal with grandmothers and mothers being most important.

Rationale 3: African American. Patriarchal groups are those that are largely headed by a male family figure. African American groups are most likely to be matriarchal. Rationale 4: Italian. Patriarchal groups are those that are largely headed by a male family figure. Italian groups are most likely to be patriarchal. Rationale 5: Arab American. Patriarchal groups are those who are largely headed by a male family figure. Arab American groups are most likely to be patriarchal. Global Rationale: Patriarchal groups are those who are largely headed by a male family figure. Appalachian families, Italian families, and Arab American families are most likely to be patriarchal. Native American and African American families are most likely to be matriarchal, or lead by a female member of the family. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify terms related to culture. Question 8 Type: MCMA The nurse is interviewing a client and wishes to determine the roles of various members of an extended family living together in one household. Which of the following statements would be helpful for the nurse to use to obtain this information? Standard Text: Select all that apply. 1. “What language is spoken in your house?” 2. “Are all of your family members working?” 3. “Tell me about the responsibilities of family members in your home.” 4. “Who makes the decisions for your family members?” 5. “Are you happy with your place in the family?” Correct Answer: 3,4 Rationale 1: “What language is spoken in your house?” The language spoken in the home will not help in the identification of roles within the household members. Rationale 2: “Are all of your family members working?” Open-ended questions are needed to obtain the most accurate and comprehensive information. This question is closed and would provide the nurse with little information other than a “yes” or “no” response.

Rationale 3: “Tell me about the responsibilities of family members in your home.” The responsibilities of the family members will allow the nurse to hear the various roles each of them holds. Rationale 4: “Who makes the decisions for your family members?” Identification of decision-making roles will aid the nurse in determining roles of the members. Rationale 5: “Are you happy with your place in the family?” Closed questions will do little to obtain information from the client. Happiness will not reflect roles of family members. Global Rationale: The language spoken in the home will not help in the identification of roles within the household members. Open-ended questions are needed to obtain the most accurate and comprehensive information. The responsibilities of the family members will allow the nurse to hear the various roles each of them holds. Identification of decision-making roles will aid the nurse in determining roles of the members. Asking if all of the family members are working and if the client is happy with his or her place in the family are closed questions and would provide the nurse with little information other than a “yes” or “no” response. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.4: Explain personal strategies that the nurse can use to develop cultural competence when assessing clients from specific cultural groups. Question 9 Type: MCSA The nurse manager is preparing for an accreditation visit and wants to assure that the unit is delivering culturally appropriate health care. Which of the following would demonstrate this approach by the nurse manager? 1. Insisting the staff teaches clients English during their hospitalization. 2. Examining the process used to admit clients. 3. Providing written materials in languages spoken most commonly by clients admitted to the unit. 4. Limiting education and training to the bedside nurses. Correct Answer: 3 Rationale 1: Requiring English be taught to clients admitted to the hospital does not promote the value of other cultures and promotes a sense of ethnocentrism. Rationale 2: The process used to admit clients may be included in the road to accreditation but does not directly address the delivery of culturally responsible care. Rationale 3: The National Standards for Culturally and Linguistically Appropriate Services in Healthcare outlines 14 valid approaches for health care to assure that cultural competency is provided.

Rationale 4: Nurses at the bedside require education to maintain competency and learn new skills. Global Rationale: The National Standards for Culturally and Linguistically Appropriate Services in Healthcare outlines 14 valid approaches for health care to assure that cultural competency is provided. Requiring English be taught to clients admitted to the hospital does not promote the value of other cultures and promotes a sense of ethnocentrism. The process used to admit clients may be included in the road to accreditation but does not directly address the delivery of culturally responsible care. Nurses at the bedside require education to maintain competency and learn new skills. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.4: Explain personal strategies that the nurse can use to develop cultural competence when assessing clients from specific cultural groups. Question 10 Type: MCSA The nurse is interviewing a client and wishes to determine health practices that are important to the client’s beliefs. Which of the following statements would be appropriate for the nurse to use to obtain this information? 1. “Do you use any nontraditional medicine?” 2. “Tell me what you do to try to improve your health.” 3. “How many times have you been sick in your life?” 4. “Do you have medical insurance?” Correct Answer: 2 Rationale 1: Asking about nontraditional medicine practices is too focused for the data the nurse is seeking. Rationale 2: The nurse should use open-ended questions when interviewing clients. This choice provides direction for the client, but allows verbalization of information to clarify health beliefs for the nurse. Rationale 3: Asking about how many times the client has been ill over a lifetime is too focused for the data the nurse is seeking. Rationale 4: Asking about whether the client has medical insurance is too focused for the data the nurse is seeking. Global Rationale: The nurse should use open-ended questions when interviewing clients. This choice provides direction for the client, but allows verbalization of information to clarify health beliefs for the nurse. Asking about nontraditional medicine practices, how many times the client has been ill over a lifetime, and whether the client has medical insurance are too focused for the data the nurse is seeking.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.4: Explain personal strategies that the nurse can use to develop cultural competence when assessing clients from specific cultural groups Question 11 Type: MCSA The nurse is caring for a client who insists on having food very hot and very cold at each meal. The nurse correctly recognizes this as a health belief in which of the following cultural groups? 1. Cuban Americans 2. Jewish Americans 3. Chinese Americans 4. Native Americans Correct Answer: 3 Rationale 1: The belief in yin and yang supports the request for the two temperature variations in the client’s meals. Cuban Americans do not support this practice. Rationale 2: The belief in yin and yang supports the request for the two temperature variations in the client’s meals. Jewish Americans do not support this practice. Rationale 3: Chinese Americans believe that health is maintained by the balance of two forces, yin and yang. This belief supports the request for the two temperature variations in the client’s meals. Rationale 4: The belief in yin and yang supports the request for the two temperature variations in the client’s meals. Native Americans do not support this practice. Global Rationale: Chinese Americans believe that health is maintained by the balance of two forces, yin and yang. This belief supports the request for the two temperature variations in the client’s meals. None of the other choices (Cuban Americans, Jewish Americans, Native Americans) support this practice. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 12 Type: MCSA

The female nurse is examining a Vietnamese male and notes that he will not make eye contact with her during the assessment. The client appears very uncomfortable and is sweating and flushed. Which of the following actions would be appropriate for the nurse in this situation? 1. Obtain a blood sugar reading. 2. Ask the client if he would like a male to perform the examination. 3. Assure the client that the exam will be over quickly. 4. Continue with the examination. Correct Answer: 2 Rationale 1: Continuing the delivery of care by obtaining a blood sugar reading is inappropriate as it does not address the client’s feelings of discomfort. Rationale 2: The Vietnamese culture prefers same-sex health care providers and may be extremely uncomfortable when the nurse does not provide this. The nurse needs to gather additional data by asking the client his preferences and allowing verbalization of his discomfort. Rationale 3: Continuing the delivery of care by offering reassurance about the examination being over quickly is inappropriate as it does not address the client’s feelings of discomfort. Rationale 4: Continuing the delivery of care by continuing the examination is inappropriate as it does not address the client’s feelings of discomfort. Global Rationale: The Vietnamese culture prefers same-sex health care providers and may be extremely uncomfortable when the nurse does not provide this. The nurse needs to gather additional data by asking the client his preferences and allowing verbalization of his discomfort. Continuing the delivery of care by obtaining a blood sugar reading, offering reassurance about the examination being over quickly, or continuing the examination are all inappropriate as they do not address the client’s feelings of discomfort. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 13 Type: MCSA The nurse is admitting a client and asks to see all medications taken on a routine basis. The client offers a long list containing prescription medications and a variety of herbal preparations that are unfamiliar names to the nurse. Which of the following actions would be appropriate for the nurse at this time? 1. Write down all the names of the herbals and look them up later.

2. Tell the client that herbals are ineffective and to throw them away. 3. Inform the healthcare provider of the herbals. 4. Ask the client what they are taken for and how often. Correct Answer: 4 Rationale 1: Looking up the herbal preparations will enhance the level of knowledge by the nurse but is not the priority action. Rationale 2: Asking the client to throw the items away will not address potential impact of their past ingestion. Rationale 3: This step should be done only after the nurse has completed the assessment as associated with these substances. Rationale 4: The nurse must assess prior to intervening and must understand that some cultures use herbal preparations in their health practices. The nurse needs to obtain additional data from the client about what the herbals are used for and how often they are taken. This information should be documented in the client’s record and thus be available to the healthcare provider. Global Rationale: The nurse must assess prior to intervening and must understand that some cultures use herbal preparations in their health practices. The nurse needs to obtain additional data from the client about what the herbals are used for and how often they are taken. This information should be documented in the client’s record and thus be available to the healthcare provider. It will enhance the level of knowledge by the nurse to look up the herbal preparations but is not the priority action. Asking the client to throw the items away will not address potential impact of their past ingestion. The remaining choices are not appropriate at this time. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.4: Explain personal strategies that the nurse can use to develop cultural competence when assessing clients from specific cultural groups. Question 14 Type: MCSA The nurse is setting up a meal tray. She notes that the client refuses to look at the food and tells the nurse to take it away. The meal contains a chicken breast, green beans, fruit cocktail, and cottage cheese. The nurse’s most appropriate response to the client at this time is which of the following? 1. “I know you are not hungry so just let me know when you want your tray.” 2. “The hospital food is horrible here.” 3. “Is there a problem with the food being sent to you?”

4. “I will get you some juice and crackers from the unit kitchen.” Correct Answer: 3 Rationale 1: While the patient may not be hungry, the nurse must determine if this is indeed the case. Rationale 2: Telling the patient the food is horrible is inappropriate and does not promote the dietary intake of the client Rationale 3: The nurse must be alert and aware of cultural preferences related to dietary habits. Further assessment in this situation is needed to obtain data about the client’s inability to look at or eat the food. Rationale 4: Offering other food options may be an option once the underlying cause for the client’s refusal is determined. Offering juice and crackers is not appropriate for the situation. Global Rationale: The nurse must be alert and aware of cultural preferences related to dietary habits. Further assessment in this situation is needed to obtain data about the client’s inability to look at or eat the food. While the patient may not be hungry, the nurse must determine if this is indeed the case. Telling the patient the food is horrible is inappropriate and does not promote the dietary intake of the client. Offering other food options may be an option once the underlying cause for the client’s refusal is determined. Offering juice and crackers is not appropriate for the situation. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.4: Explain personal strategies that the nurse can use to develop cultural competence when assessing clients from specific cultural groups. Question 15 Type: MCMA When preparing to perform a cultural assessment for a client, the nurse is aware of the numerous components that will aid in the identification of ethnicity. When preparing to ask appropriate questions to assess unique needs, which of the following questions will be beneficial? Standard Text: Select all that apply. 1. “What is your religious preference?” 2. “Can you identify any food practices that will impact your prescribed plan of care?” 3. “To what ethnic group do you identify yourself?” 4. “Does your mother practice the same religion as you?” 5. “What political party do you belong to?”

Correct Answer: 1,2,3 Rationale 1: What is your religious preference? Religious preference determination is a component of the cultural assessment. Rationale 2: Can you identify any food practices which will impact your prescribed plan of care?” Dietary preferences are deeply ingrained into cultural beliefs and preferences. Assessment of dietary restrictions or preferences is a component of the cultural assessment. Rationale 3: “To what ethnic group do you identify yourself?” Ethnicity involves both internal and external identification practices. The nurse must ask what the client prefers. Rationale 4: “Does your mother practice the same religion as you?” Although families frequently practice the same religion it is not appropriate to make this inquiry. Rationale 5: “What political party do you belong to?” Politics are a component of ethnicity but are not a requirement nor an appropriate question for the admission assessment. Global Rationale: Religious preference determination is a component of the cultural assessment. Dietary preferences are deeply ingrained in cultural beliefs and preferences. Assessment of dietary restrictions or preferences is a component of the cultural assessment. Ethnicity involves both internal and external identification practices. The nurse must ask what the client prefers. Although families frequently practice the same religion it is not appropriate to make this inquiry. Politics are a component of ethnicity but are not a requirement nor an appropriate question for the admission assessment. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify terms related to culture. Question 16 Type: MCSA While acting as a preceptor for a graduate nurse, the registered nurse notices the graduate nurse voices frustration and a lack of appreciation for the health care beliefs and practices of clients whose beliefs differ from her own. Which of the following actions will best assist the preceptor to improve the graduate’s practice? 1. The nurse should advise the graduate to reduce displays of frustration and lack of appreciation for the values of others. 2. The nurse should encourage the graduate to look closely at the graduate’s own cultural practices and beliefs. 3. The graduate should receive a written reprimand. 4. The graduate should be required to meet with a counselor concerning her ethnic biases. Correct Answer: 2

Rationale 1: Simply reducing the comments and displays of frustration will not address the root cause of the problem. The underlying cause must be handled to resolve the issue. Rationale 2: Ethnocentrism is the belief of one’s personal beliefs to be superior to those held by others. The best manner in which to begin to manage and reduce these feelings is to begin the process of self-awareness. Rationale 3: Administering a written reprimand will not handle the existing problem. The underlying cause must be handled to resolve the issue. Rationale 4: Counseling and discipline may be warranted later in the process if the behaviors continue or worsen. Global Rationale: Ethnocentrism is the belief of one’s personal beliefs to be superior to those held by others. The best manner in which to begin to manage and reduce these feelings is to begin the process of self-awareness. Simply reducing the comments and displays of frustration will not address the root cause of the problem. The underlying cause must be handled to resolve the issue. Administering a written reprimand will not handle the existing problem. Counseling and discipline may be warranted later in the process if the behaviors continue or worsen. Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.4: Explain personal strategies that the nurse can use to develop cultural competence when assessing clients from specific cultural groups. Question 17 Type: MCSA The nurse is assigned to provide care to a diabetic client who indicated being a Muslim on the admission assessment. When planning the care for the shift, which of the following factors may have the greatest impact on the care? 1. The client has a strong respect for the elders in the family. 2. Pork in the diet is forbidden. 3. The client may practice religious fasting. 4. Lamb and chicken are the main sources of protein. Correct Answer: 3 Rationale 1: The respect for elders in the family is not a detriment to the successful plan of care. Rationale 2: The lack of pork in the diet does not hinder dietary planning. Rationale 3: During special religious events Muslims participate in fasting during the daylight hours. The diabetic client who engages in fasting and the nurse providing care will face unique challenges.

Rationale 4: Lamb and chicken provide adequate, healthful alternatives. Global Rationale: During special religious events Muslims participate in fasting during the daylight hours. The diabetic client who engages in fasting and the nurse providing care will face unique challenges. The lack of pork in the diet does not hinder dietary planning. Lamb and chicken provide adequate, healthful alternatives. The respect for elders in the family is not a detriment to the successful plan of care. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 18 Type: MCSA The nurse is charge nurse for the shift. Three of the staff members are female and one is male. Which of the following clients should be assigned to a female staff member? 1. The African American female 2. The African American male 3. The Arab American male 4. The Arab American female Correct Answer: 4 Rationale 1: The African American female would likely not have difficulty being assigned to the patient load of the male staff nurse. Rationale 2: The African American male would likely not have difficulty being assigned to the patient load of the male staff nurse. Rationale 3: The Arab American male would likely not have difficulty being assigned to the patient load of the male staff nurse. Rationale 4: The teachings and beliefs of Arab Americans restrict physical touch between unmarried males and females. Global Rationale: The teachings and beliefs of Arab Americans restrict physical touch between unmarried males and females. The African American female and male and the Arab American male would likely not have difficulty being assigned to the patient load of the male staff nurse. Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 19 Type: MCSA When providing an inservice to new graduate nurses, the nurse educator discusses expectations for the nursing staff concerning the acceptance of client cultural beliefs. Which of the following statements by a participant indicates further teaching is needed? 1. “The acceptance of different cultural values is needed to provide quality nursing care.” 2. “Cultural values may dictate my client assignments on the nursing unit.” 3. “My own cultural values are irrelevant to the acceptance of the values of others.” 4. “My knowledge of the cultural values of others will increase in time.” Correct Answer: 3 Rationale 1: Failure to have self-awareness can result in ethnocentrism. Rationale 2: The cultural values and beliefs of the client may require “sensitive” scheduling. Rationale 3: The knowledge and acceptance of one’s own cultural values is essential to the acceptance and awareness of the values of the client. Rationale 4: Time does allow the nurse to develop additional knowledge of many issues in nursing, including cultural considerations. Global Rationale: The knowledge and acceptance of one’s own cultural values is essential to the acceptance and awareness of the values of the client. Failure to have self-awareness can result in ethnocentrism. The cultural values and beliefs of the client may require “sensitive” scheduling. Time does allow the nurse to develop additional knowledge of many issues in nursing, including cultural considerations. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4.3: Describe cultural phenomena that impact healthcare Question 20 Type: MCSA The nurse is collecting data concerning the client’s chief complaint. The client reports having attempted to manage the illness using herbs. Which of the following responses by the nurse is most therapeutic? 1. “What herbs have been used to manage your condition?”

2. “Does your healthcare provider know about your herbal remedies?” 3. “Don’t you realize your recovery may have been impeded by these herbal preparations?” 4. “When was the last dosage of the herbal remedies taken?” Correct Answer: 1 Rationale 1: The comprehensive assessment of health requires the nurses to obtain as much information as possible. The nurse will need to determine the herbs in use to ensure there are not adverse interactions between the treatments that may be ordered by the healthcare provider. Rationale 2: Asking about the healthcare provider’s knowledge of the remedies and the implications made concerning the potential damage caused by the herbs are presented in closed questions. Further, they may imply to clients that they have engaged in wrongdoing. Rationale 3: Asking about the healthcare provider’s knowledge of the remedies and the implications made concerning the potential damage caused by the herbs are presented in closed questions. Further, they may imply clients that they have engaged in wrongdoing. Rationale 4: The last dosage of the herbal remedies may be beneficial; however, it is not the most therapeutic question to be asked. Global Rationale: The comprehensive assessment of health requires the nurses to obtain as much information as possible. The nurse will need to determine the herbs in use to ensure there are not adverse interactions between the treatments that may be ordered by the healthcare provider. Asking about the healthcare provider’s knowledge of the remedies and the implications made concerning the potential damage caused by the herbs are presented in closed questions. Closed questions limit the amount of information obtained. Further, they may imply to the client they have engaged in wrongdoing. The last dosage of the herbal remedies may be beneficial; however, it is not the most therapeutic question to be asked. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 21 Type: MCSA The nurse is preparing to perform an assessment of the client’s social support and organization. Which of the following questions will provide the needed information? 1. Where was the client born? 2. What is the primary language spoken in the family home? 3. What nonverbal communication behaviors are observed during the nurse-client interaction?

4. Is there a religious affiliation linked with the cultural affiliation? Correct Answer: 4 Rationale 1: Finding out the location of the client’s birth provides information concerning ethnicity. Rationale 2: The primary language spoken in the home is of importance but does not determine the client’s social support. Rationale 3: Communication patterns are identified by the types of nonverbal behaviors observed. Rationale 4: During the data collection phase, data are collected to determine the social organization of the client. Assessment of religious affiliation / cultural affiliation will provide information concerning the social organization of the client. Global Rationale: During the data collection phase, data are collected to determine the social organization of the client. Assessment of religious affiliation / cultural affiliation will provide information concerning the social organization of the client. Finding out the location of the client’s birth provides information concerning ethnicity. The primary language spoken in the home is of importance but does not determine the client’s social support. Communication patterns are identified by the types of nonverbal behaviors observed. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify terms related to culture. Identify terms related to culture. Question 22 Type: MCSA While working in an ambulatory care clinic, a Hispanic client who speaks limited English seeks care. When preparing to provide the discharge instructions to the client, what are the responsibilities of the nurse? 1. The nurse is required to provide the client with an English-to-Spanish translation dictionary. 2. The nurse should provide instructions written in English along with the contact number for a translator. 3. The nurse has the responsibility to seek all available resources to provide information the client will understand. 4. The nurse is expected to provide a translator fluent in the client’s primary language. Correct Answer: 3 Rationale 1: Providing a translation dictionary does not ensure the client has adequate information to understand the plan of care.

Rationale 2: The types of resources available will vary depending upon the geographical area of the clinic as well as the language spoken and understood by the client. Translator availability will vary. Rationale 3: The nurse has the responsibility to seek available resources to ensure the client understands the care and treatment being provided. Rationale 4: The types of resources available will vary depending upon the geographical area of the clinic as well as the language spoken and understood by the client. Global Rationale: The nurse has the responsibility to seek available resources to ensure the client understands the care and treatment being provided. The types of resources available will vary depending upon the geographical area of the clinic as well as the language spoken and understood by the client. Providing a translation dictionary does not ensure the client has adequate information to understand the plan of care. Translator availability will vary. Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.4: Explain personal strategies that the nurse can use to develop cultural competence when assessing clients from specific cultural groups. Question 23 Type: MCSA The nurse is assigned to provide postoperative care to a Chinese American client. Which of the following traditional Chinese cultural concepts may impact the nurse-client interaction? 1. The client may dislike being touched by strangers. 2. Health is associated with being overweight. 3. There is a strong belief in the use of herbs to manage illness. 4. Ceremonies are an important part in the recognition of illness and disease. Correct Answer: 1 Rationale 1: The Chinese American client may dislike being touched by strangers. Rationale 2: The association of health and being overweight is a traditional belief of the Cuban American client. Rationale 3: The use of herbs is a traditional belief of the Cuban American client. Rationale 4: The use of ceremonies is a traditional belief of the Cuban American client.

Global Rationale: The Chinese American client may dislike being touched by strangers. The association of health and being overweight, and the use of herbs and ceremonies are the traditional beliefs of the Cuban American client. Cognitive Level: Understanding Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 24 Type: MCSA A Filipino American is preparing for discharge from the hospital. While providing instructions concerning followup care, the nurse notes the client is nodding in agreement in response to the nurse’s statements. After completing the exchange of information, which of the following actions should the nurse take first? 1. The client’s understanding of the discharge instructions should be documented. 2. The nurse should ask the client if she understood the information being relayed. 3. The nurse should ask the client questions to assess understanding of the information provided. 4. The client should be asked to sign the discharge paperwork. Correct Answer: 3 Rationale 1: The client’s nodding may simply indicate hearing the information being provided. Rationale 2: Asking the client if she understands is a closed question and may not determine adequate information. Rationale 3: The client’s nodding may simply indicate hearing the information being provided. The nurse should ask questions to assess understanding. Rationale 4: The client’s signature on the discharge paperwork may be indicated as a part of the discharge plan but is not the next step that should be taken by the nurse. Global Rationale: The client’s nodding may simply indicate hearing the information being provided. The nurse should ask questions to assess understanding. Asking the client if she understands is a closed question and may not determine adequate information. The client’s signature on the discharge paperwork may be indicated as a part of the discharge plan but is not the next step that should be taken by the nurse. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4.3: Describe cultural phenomena that impact health care.

Question 25 Type: MCSA When planning care to manage osteoporosis in an African American client, which of the following must be taken into consideration? 1. The daily dietary intake contains bread at every meal. 2. Snacks often replace meals beginning in adolescence. 3. Lactose intolerance may be a factor. 4. Pork is not allowed in the diet. Correct Answer: 3 Rationale 1: Bread and pork are factors to be considered when providing nutritional care to the Arab American. Rationale 2: Snacking during adolescence is a health concern for the Appalachian population. Rationale 3: Lactose intolerance is estimated to affect 75% of the African American population. This factor may impact dietary choices available and recommended to manage osteoporosis. Rationale 4: Bread and pork are factors to be considered when providing nutritional care to the Arab American. Global Rationale: Lactose intolerance is estimated to affect 75% of the African American population. This factor may impact dietary choices available and recommended to manage osteoporosis. Bread and pork are factors to be considered when providing nutritional care to the Arab American. Snacking during adolescence is a health concern for the Appalachian population. In addition, bread, pork, and snacks do not relate to osteoporosis. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 26 Type: MCSA The nurse is caring for a Jewish client with type 1 diabetes mellitus who has been taken to another department for testing. The nurse recognizes the client will be due for an insulin injection and will need to eat immediately upon arrival back to the unit. The nurse orders the client’s meal tray. Which of the following will be the best selection? 1. BLT sandwich, potato salad, fruit wedge, and unsweetened tea 2. Roast beef sandwich, potato chips, and 2% milk

3. Egg salad sandwich, side salad, applesauce, and diet soda. 4. Pork tenderloin sandwich, fruit cup, and milk. Correct Answer: 3 Rationale 1: The Jewish client is least likely to be accepting of meals containing pork. Rationale 2: Meat and milk are not served in the same meal. Rationale 3: The Jewish client is least likely to be accepting of meals containing pork. The menu of egg salad, a side salad, applesauce, and diet soda does not violate Jewish religious customs. Rationale 4: The Jewish client is least likely to be accepting of meals containing pork. In addition, meat and milk are not served in the same meal. Global Rationale: The Jewish client is least likely to be accepting of the meal containing pork. In addition, meat and milk are not served in the same meal. The menu of egg salad, a side salad, applesauce, and diet soda does not violate Jewish religious customs. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 27 Type: MCSA A Filipino American client is discussing concerns related to osteoporosis with the nurse educator. When considering the information to be presented, the nurse is aware that which of the following traditional characteristics may pose problems for this client’s plan of care and will need to be incorporated into the information provided? 1. Potential for lactose intolerance 2. Pork is a primary source of protein 3. Heavy use of salt and vinegar 4. Chicken is a primary source of protein Correct Answer: 1 Rationale 1: The Filipino American has a higher than average risk to be lactose intolerant. Lactose intolerance may make ingestion of dairy products challenging. Rationale 2: The client’s preferred sources of protein are not a source of concern.

Rationale 3: The use of salt and vinegar for seasoning are not concerns for the client who has concerns related to osteoporosis. Rationale 4: The client’s preferred sources of protein are not a source of concern. Global Rationale: The Filipino American has a higher than average risk to be lactose intolerant. Lactose intolerance may make ingestion of dairy products challenging. The client’s preferred sources of protein are not a source of concern. The use of salt and vinegar for seasoning are not concerns for the client who has concerns related to osteoporosis. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 28 Type: MCSA The nurse is caring for a Vietnamese female client. When planning to provide care the nurse should include understanding of which of the following concepts? 1. The client will be most respectful of the nurse if direct eye contact is maintained. 2. The client may require a greater than usual amount of personal space. 3. The client will use periods of silence to indicate acceptance of the care interventions proposed. 4. The client will appreciate the nurse’s attempt to engage in a casual discussion about her feelings. Correct Answer: 2 Rationale 1: The culture often does not engage in direct eye contact as it is deemed disrespectful. Rationale 2: The traditional Vietnamese client will appreciate an increase allowance of personal space. Rationale 3: Periods of silence are used to demonstrate negative emotion. Rationale 4: Discussion of personal feelings is discouraged. Global Rationale: The traditional Vietnamese client will appreciate an increase allowance of personal space. The culture often does not engage in direct eye contact as it is deemed disrespectful. Periods of silence are used to demonstrate negative emotion. Discussion of personal feelings is discouraged. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 29 Type: MCSA The nurse caring for a Navajo woman notices the client is often quiet when she is attempting to interact with her. What inferences can best be made about this behavior? 1. The client likely does not understand the nurse’s attempts to engage her. 2. The client is demonstrating disapproval with the nurse through the use of silence. 3. The client is uneasy speaking with the nurse without the male head of her household. 4. The client is illustrating agreement with the nurse’s actions by using silence. Correct Answer: 4 Rationale 1: There is no indication the client is having difficulty understanding the interaction. Rationale 2: There is no indication the client is failing to agree with the nurse. Rationale 3: There is no indication the client is having difficulty speaking with the nurse without the male head of her household. Rationale 4: The use of silence in the Navaho culture indicates agreement. In differing cultures silence may indicate a lack of understanding, disapproval, or discomfort. Global Rationale: The use of silence in the Navaho culture indicates agreement. In differing cultures silence may indicate a lack of understanding, disapproval, or discomfort. There is no indication the client is having difficulty understanding the interaction, is failing to agree with the nurse, or is having difficulty speaking with the nurse without the male head of her household. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3: Describe cultural phenomena that impact health care. Question 30 Type: MCMA The nurse educator is discussing culture and ethnicity with a group of student nurses. Which statement by a student indicates the need for further education? Standard Text: Select all that apply. 1. “The gene pool in the United States has become less diverse over the past decade.”

2. “I have found it easiest to classify individuals with cultural groups by assessing their skin tones and facial features.” 3. “When identifying individuals of the same race, they will have shared genetic heritage, biologic and physiologic characteristics.” 4. “Ethnic groups share common values over generations.” 5. “An individual may self-identify with an ethnic group that is different from the ethnic group of their birth or race.” Correct Answer: 1,2,3 Rationale 1: “The gene pool in the United States has become less diverse over the past decade.” The United States represents a population of diverse individuals. There has been an increase in blending races. Many individuals now classify themselves as biracial or multiracial. Rationale 2: “I have found it easiest to classify individuals with cultural groups by assessing their skin tones and facial features.” The use of skin tone or facial features is not an acceptable means to determine racial or cultural heritage. This method of assessment and classification is shortsighted and may result in errors. Rationale 3: “When identifying individuals of the same race they will have shared genetic heritage, biologic and physiologic characteristics.” Genetic heritage and biologic and physiologic characteristics may not all be shared between all members of the same race. Rationale 4: “Ethnic groups share common values over generations.” The awareness of belonging to a group in which certain characteristics or aspects such as culture and biology differentiate the members of one group from another is the concept of ethnicity. It is defined by a shared interest, heritage, religion, food, politics, or geography and nationality Rationale 5: “An individual may self identify with an ethnic group that is different from the ethnic group of their birth or race.” Inclusion in an ethnic group may be self-directed. An individual may share the viewpoints, geography, and nationality of an ethnic group by personal choice. Global Rationale: The United States represents a population of diverse individuals. There has been an increase in blending races. Many individuals now classify themselves as biracial or multiracial. The use of skin tone or facial features is not an acceptable means to determine racial or cultural heritage. This method of assessment and classification is shortsighted and may result in errors. Genetic heritage and biologic and physiologic characteristics may not all be shared between all members of the same race. The awareness of belonging to a group in which certain characteristics or aspects such as culture and biology differentiate the members of one group from another is the concept of ethnicity. It is defined by a shared interest, heritage, religion, food, politics, or geography and nationality. Inclusion in an ethnic group may be self-directed. An individual may share the viewpoints, geography, and nationality of an ethnic group by personal choice. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4.2: Identify terms related to culture.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 5 Question 1 Type: MCSA The nurse is caring for a woman in the emergency room who is complaining of chest pain. She states that she was walking from her apartment to the grocery store when the pain became very severe. She reported that people were following her. She said she couldn’t really see them but she could hear them talking about “grabbing me.” While the woman is explaining the event, she alternates between wringing her hands and manipulating the items in her purse over and over. The nurse would obtain what further assessment data in this situation? 1. Spiritual affiliations 2. Dietary preferences and habits 3. Review of systems 4. Focused psychosocial interview Correct Answer: 4 Rationale 1: A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited. Rationale 2: A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited. Rationale 3: The physical examination is conducted after the interviewing is complete. Rationale 4: The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted. Global Rationale: The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted. A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited. The physical examination is conducted after the interviewing is complete. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 2 Type: MCSA

The nurse is interviewing a client prior to a physical examination. The client tells the nurse that she has been experiencing a lot of aches, pains, and abdominal discomfort. The nurse may suspect which of the following factors that impact physical health? 1. Income 2. Stress 3. Ethnicity 4. Occupation Correct Answer: 2 Rationale 1: Income may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. Rationale 2: Stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to “feel better.” Rationale 3: Ethnicity may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. Rationale 4: Occupation may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. Global Rationale: All of the above factors may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to “feel better.” Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.3: Identify factors affecting psychosocial health. Question 3 Type: MCSA The nurse is interviewing an overweight teenager who looks downward and speaks softly when answering questions. The nurse identifies a problem with client’s self-concept. Which of the following findings would support the nurse’s conclusions? 1. Increased desire to form lasting relationships 2. Decreased ability to form attachments with other people

3. Inability to maintain stable employment 4. Feelings of worthlessness, anxiety, and/or depression Correct Answer: 4 Rationale 1: The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts. Rationale 2: Decreased ability to form attachments to other people results from many factors not limited to poor self-concept. Rationale 3: Decreased ability to maintain stable employment results from many factors not limited to poor selfconcept. Rationale 4: Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues. Global Rationale: Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues. Decreased ability to maintain stable employment and to form attachments to other people results from many factors not limited to poor self-concept. The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts. Cognitive Level: Remembering Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.1: Describe psychosocial functioning. Question 4 Type: MCSA A 7-year-old client was just admitted to the hospital following an appointment in the pediatric oncology clinic. His mother, who is distraught over his recent leukemic relapse, accompanies the child. She is crying and asking, “What did I do wrong? ... Why does he deserve this? ... Why can’t it be me?” The nurse understands that these statements indicate which of the following? 1. Ineffective coping 2. Emotional emptiness 3. Spiritual distress 4. Psychologic anxiety Correct Answer: 3

Rationale 1: Those types of statements are common responses to a serious diagnosis and do not indicate ineffective coping. Rationale 2: Emotional emptiness is not an acceptable term to describe behaviors indicating distress. Rationale 3: Questions such as “What did I do wrong?” and “Why does he deserve this?” indicate spiritual distress. Rationale 4: Further evidence would be required before determining psychologic anxiety. Global Rationale: Questions such as “What did I do wrong?” and “Why does he deserve this?” indicate spiritual distress. Further evidence would be required before determining psychologic anxiety. Emotional emptiness is not an acceptable term to describe behaviors indicating distress. Those types of statements are common responses to a serious diagnosis and do not indicate ineffective coping. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5.3: Identify factors affecting psychosocial health. Question 5 Type: MCSA The nurse has gathered assessment data on a client admitted for suicidal tendencies. The nurse develops appropriate nursing diagnoses and formulates goals to achieve client outcomes. The nurse is utilizing which step of the nursing process? 1. Implementation 2. Evaluation 3. Planning 4. Assessment Correct Answer: 3 Rationale 1: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. Rationale 2: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. Rationale 3: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Rationale 4: Assessment is the process by which data are collected.

Global Rationale: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. Assessment is the process by which data are collected. Cognitive Level: Remembering Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 6 Type: MCSA The nurse is assessing a client in an outpatient mental health setting. The assessment tool outlines criteria for psychosocial health. The nurse understands that this term may be defined as which of the following? 1. The state of being emotionally balanced and socially astute. 2. Being mentally stable, physically fit, and psychologically well. 3. Becoming spiritually and psychologically mature. 4. The state of being mentally, emotionally, socially, and spiritually well. Correct Answer: 4 Rationale 1: Emotionally balanced is another way of referring to emotionally well, though the term is not often used. Being socially astute is a characteristic that one may develop but is not necessary for social wellness. Rationale 2: Mental stability is a component of psychosocial health and includes psychologic health. Being physically fit may influence psychosocial health, but individuals may be not physically fit but still in good psychosocial health Rationale 3: Many would argue that children are not spiritually and psychologically mature, yet may exhibit psychosocial health, so being spiritually and psychologically mature are not criteria for psychosocial health. Rationale 4: Psychosocial health is defined as being mentally, emotionally, socially, and spiritually well. Global Rationale: Psychosocial health is defined as being mentally, emotionally, socially, and spiritually well. Mental stability is a component of psychosocial health and includes psychologic health. Being physically fit may influence psychosocial health, but individuals may be not physically fit but still in good psychosocial health. Many would argue that children are not spiritually and psychologically mature, yet may exhibit psychosocial health, so being spiritually and psychologically mature are not criteria for psychosocial health. The same is true with being emotionally balanced and socially astute. Emotionally balanced is another way of referring to emotionally well, though the term is not often used. Being socially astute is a characteristic that one may develop but is not necessary for social wellness.

Cognitive Level: Remembering Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 7 Type: MCSA The nurse is conducting a class on health promotion and uses the following definition: “The ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands.” The nurse is stressing which of the following areas? 1. Physical fitness 2. Emotional health 3. Physical health 4. Psychologic well-being Correct Answer: 1 Rationale 1: Physical fitness is the ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands. Rationale 2: Physical fitness is an important component of physical and emotional health. Rationale 3: Physical fitness is an important component of physical and emotional health. Rationale 4: Physical fitness influences mental alertness and emotional stability, as well as a general feeling of well-being, which some may call psychologic fitness. Global Rationale: Physical fitness is the ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands. Physical fitness is an important component of physical and emotional health. Physical fitness influences mental alertness and emotional stability, as well as a general feeling of well-being, which some may call psychologic fitness. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1: Describe psychosocial functioning. Question 8 Type: MCSA

The nurse is caring for a client admitted for severe weight loss and depression. The client has recently experienced the loss of three close family members and has withdrawn from all social activities. In developing the plan of care, the nurse would correctly choose which of the following nursing diagnoses? 1. Powerlessness 2. Anxiety 3. Dysfunctional grieving 4. Spiritual distress Correct Answer: 3 Rationale 1: Powerlessness refers to feelings of a loss of control with the situation. Rationale 2: Anxiety infers feelings of apprehension. Rationale 3: Clients experiencing tremendous loss often develop depression as part of their reaction to grief. However, this depression should also be seen with other stages of the grieving process such as denial, anger, bargaining, and acceptance. Clients remaining in one stage of the grieving process may not be progressing toward acceptance. Rationale 4: Spiritual distress infers the client would be at odds with her feelings. Global Rationale: Clients experiencing tremendous loss often develop depression as part of their reaction to grief. However, this depression should also be seen with other stages of the grieving process such as denial, anger, bargaining, and acceptance. Clients remaining in one stage of the grieving process may not be progressing toward acceptance. There are not enough data to support the remaining nursing diagnoses. Powerlessness refers to feelings of a loss of control with the situation. Anxiety infers feelings of apprehension. Spiritual distress infers the client would be at odds with her feelings. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 9 Type: MCSA The nurse is reviewing the plan of care for a client and notes that the following goal has not been met: “Client will verbalize three positive things about himself.” The nurse would correctly choose to do which of the following? 1. Tell the client three things that he does well. 2. Ask other clients to tell the client what he does well.

3. Determine barriers to achieving the goal. 4. Do nothing as long as the client appears better. Correct Answer: 3 Rationale 1: Telling the client things that he does well will not aid in the achievement of the goal. Rationale 2: Involving other clients in the plan of care may be a violation of the client’s privacy and is not appropriate. Rationale 3: The nursing process must be approached in a cyclic and systematic fashion in order to best meet the identified needs of clients. When goals are not met within established time frames, the nurse must examine potential reasons for this and develop new interventions and time frames for goal achievement. Rationale 4: Ignoring the absence of progression toward the established goal will not aid the client in improving. Global Rationale: The nursing process must be approached in a cyclic and systematic fashion in order to best meet the identified needs of clients. When goals are not met within established time frames, the nurse must examine potential reasons for this and develop new interventions and time frames for goal achievement. The goal statements are based upon the client’s achievements. Telling the client things that he does well will not aid in the achievement of the goal. Involving other clients in the plan of care may be a violation of the client’s privacy and is not appropriate. Ignoring the absence of progression toward the established goal will not aid the client in improving. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 10 Type: MCMA A client is admitted to the orthopedic unit after breaking an arm after a fall. The client appears disheveled and has a body odor. The family arrives and expresses surprise at the client’s appearance. They report that this is not the normal appearance of the client and that they are usually clean and meticulously groomed. Which of the following assessments does the nurse need to complete in order to formulate relevant nursing diagnoses and a plan of care for this patient? Standard Text: Select all that apply. 1. Food preferences 2. Psychosocial assessment 3. Memory assessment and orientation

4. Family medical history 5. Body systems examination Correct Answer: 2,3,4,5 Rationale 1: Food preferences. Collection of dietary preferences is completed on clients when they are admitted to a facility, however, this information will not provide an explanation for the changes being noted in the client’s behaviors. Rationale 2: Psychosocial assessment. The client’s appearance indicates there has been some change in mental outlook or condition. These changes may be the result of psychosocial issues and they must be investigated. Rationale 3: Memory assessment and orientation. The client’s appearance indicates there has been some change in mental outlook or condition. The client’s memory and level of orientation will provide information relating to potential causes. This assessment will also provide an indication as to the seriousness of the problems being noted. Rationale 4: Family medical history. The client’s presentation is indicative of a problem. Some disorders may be genetic, thus requiring investigation. Rationale 5: Body systems examination. The assessment of the client’s body systems will yield clues as to the cause of the changes being noted in behavior. Global Rationale: Collection of dietary preferences is completed on clients when they are admitted to a facility, however, this information will not provide an explanation for the changes being noted in the client’s behaviors. The client’s appearance indicates there has been some change in mental outlook or condition. These changes may be the result of psychosocial issues and they must be investigated. The client’s memory and level of orientation will provide information relating to potential causes. This assessment will also provide an indication as to the seriousness of the problems being noted. Some disorders may be genetic, thus requiring investigation. The assessment of the client’s body systems will yield clues as to the cause of the changes being noted in behavior. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 11 Type: MCSA The nurse is reviewing the care plan for a client who is being treated for schizophrenia. The client had been hearing voices for quite some time, but now doesn’t state or deny that voices are heard. The nurse notes that the established goals have been met—the client is interacting appropriately with staff and family, is well-groomed, and has expressed excitement about the discharge. The nurse is using which step of the nursing process? 1. Goal setting

2. Implementation 3. Diagnosis 4. Evaluation Correct Answer: 4 Rationale 1: Goal setting occurs after a diagnosis has been formulated. Rationale 2: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. Rationale 3: The diagnosis is formulated after data have been collected. Rationale 4: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. The nurse’s recorded observations indicate the goals of the nursing care plan have been achieved. Global Rationale: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. The nurse’s recorded observations indicate the goals of the nursing care plan have been achieved. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. The diagnosis is formulated after data have been collected, and goal setting occurs after a diagnosis has been formulated. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 12 Type: MCMA The nurse is admitting a client to a psychiatric facility and is planning to conduct a psychosocial assessment. The nurse would correctly choose which of the following tools to obtain this data? Standard Text: Select all that apply. 1. Healthy Day Measures 2. Multidimensional Health Profile 3. Emotional Readiness Assessment Profile 4. Holmes Social Readjustment Scale 5. Duke Social Support and Stress Scale

Correct Answer: 1,2,4,5 Rationale 1: Healthy Day Measures. The Healthy Day Measures is used by the Centers for Disease Control and Prevention. The scale is used to measure the quality of life. Rationale 2: Multidimensional Health Profile. The Multidimensional Health Profile is a tool used to assess psychosocial problems. The tool specifically targets stress, coping, social supports, and mental health. Rationale 3: Emotional Readiness Scale. The Emotional Readiness Scale is not a true test, and therefore not a valid test to assess psychosocial variables in a client. Rationale 4: Holmes Social Readjustment Scale. The Holmes Social Readjustment Scale is used to measure the stressors in a client’s life. Rationale 5: Duke Social Support and Stress Scale. The Duke Social Support and Stress scale is an instrument to measure family and nonfamily support and stress. Global Rationale: The Healthy Day Measures is used by the Centers for Disease Control and Prevention. The scale is used to measure the quality of life. The Multidimensional Health Profile is a tool used to assess psychosocial problems. The tool specifically targets stress, coping, social supports, and mental health. The Emotional Readiness Scale is not a true test, and therefore not a valid test to assess psychosocial variables in a client. The Holmes Social Readjustment Scale is used to measure the stressors in a client’s life. The Duke Social Support and Stress scale is an instrument to measure family and nonfamily support and stress. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 13 Type: MCSA While being interviewed, a client admits to the nurse that she has been hearing voices and sounds for the past three days. Which of the following would be the nurse’s best response in this situation? 1. “How long have you been hearing these voices?” 2. “Tell me about what the voices tell you to do.” 3. “These must be other things you are hearing.” 4. “Do the voices bother you during the night only?” Correct Answer: 2 Rationale 1: Knowing the length of time a person has had auditory hallucinations is helpful but is not the most important next question. Also, the client already said that she had been hearing the voices for 3 days.

Rationale 2: The most appropriate next question after the client tells the nurse she hears voices is asking the client if the voices tell her what she must do. Command hallucinations are dangerous and may lead to selfdestructive behavior or harm to other people or property. Rationale 3: Telling the client that there cannot be voices may indicate your lack of belief regarding in what is being said. This may cause refusal to answer additional questions. Rationale 4: Asking whether or not the voices are bothersome to the client only at night does not yield helpful information as hallucinations are not a normal phenomenon and treatment goals would include eliminating the hallucinations. Additionally, the goal of the interview is to obtain the information most important to the treatment plan and is not to dwell on the hallucinations, thereby reinforcing them to the patient. Global Rationale: The most appropriate next question after the client tells the nurse she hears voices is asking the client if the voices tell her what she must do. Command hallucinations are dangerous and may lead to selfdestructive behavior or harm to other people or property. Telling the client that there cannot be voices may indicate your lack of belief regarding in what is being said. This may cause refusal to answer additional questions. Knowing the length of time a person has had auditory hallucinations is helpful but is not the most important next question. Also, the client already said that she had been hearing the voices for 3 days. Asking whether or not the voices are bothersome to the client only at night does not yield helpful information as hallucinations are not a normal phenomenon and treatment goals would include eliminating the hallucinations. Additionally, the goal of the interview is to obtain the information most important to the treatment plan and is not to dwell on the hallucinations, thereby reinforcing them to the patient. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 14 Type: MCSA The nurse is caring for a confused client. The nurse informs the client of the date, day of the week, time, and location each time the room is entered. The nurse is utilizing which step of the nursing process? 1. Implementation 2. Evaluation 3. Planning 4. Assessment Correct Answer: 1 Rationale 1: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. A confused client needs reorientation as part of the nursing care provided.

Rationale 2: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. Rationale 3: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Rationale 4: Assessment is the phase of obtaining subjective and objective data about the client. Global Rationale: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. A confused client needs reorientation as part of the nursing care provided. Assessment is the phase of obtaining subjective and objective data about the client. During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 15 Type: MCSA The nurse is completing the psychosocial history on a newly admitted adult client. The client reports trouble concentrating, rapid heartbeats, irritability, and inability to make decisions. The nurse suspects which of the following? 1. Stress reaction 2. Role confusion 3. Impending heart attack 4. Dysfunctional anxiety Correct Answer: 1 Rationale 1: A high level of stress may result in symptoms such as irritability, indecisiveness, confusion, pounding heart or pulse, and trouble concentrating, among other symptoms. Rationale 2: There are no data to support the concern of role confusion. Rationale 3: Symptoms of an impending heart attack may include irritability, confusion, and a pounding heart rate but there are other more classic symptoms that typically also appear. Rationale 4: Symptoms of anxiety include some of the above symptoms, but there is not enough evidence to call it dysfunctional.

Global Rationale: A high level of stress may result in symptoms such as irritability, indecisiveness, confusion, pounding heart or pulse, and trouble concentrating, among other symptoms. Symptoms of an impending heart attack may include irritability, confusion, and a pounding heart rate but there are other more classic symptoms that typically also appear. Symptoms of anxiety include some of the above symptoms, but there is not enough evidence to call it dysfunctional. There are also no data to support the concern of role confusion. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5.2: Define psychosocial health. Question 16 Type: MCSA An elderly, hard-of-hearing client is observed not participating with conversation and sits quietly in the corner of the room. This client’s physical ailment is impacting which psychosocial dimension? 1. Mental 2. Emotional 3. Social 4. Spiritual Correct Answer: 3 Rationale 1: Mental functioning refers to the ability to cognitively process and interact with the environment. Rationale 2: The emotional dimension is subjective and includes one’s feelings. Rationale 3: Psychosocial health includes mental, emotional, social, and spiritual dimensions. When one part is missing or dysfunctional, all other parts of the individual are affected. Social functioning refers to the ability to form relationships with others. Rationale 4: Spirituality refers to the beliefs and values that give meaning to life. Global Rationale: Psychosocial health includes mental, emotional, social, and spiritual dimensions. When one part is missing or dysfunctional, all other parts of the individual are affected. Social functioning refers to the ability to form relationships with others. The emotional dimension is subjective and includes one’s feelings. Mental functioning refers to the ability to cognitively process and interact with the environment. Spirituality refers to the beliefs and values that give meaning to life. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5.1: Describe psychosocial functioning. Question 17 Type: MCSA The adult caregiver of an elderly client states, “When my mother takes ill, you can predict I’ll be sick in about 6 weeks.” This statement demonstrates: 1. The client has a communicable disease. 2. The caregiver has uncared for health problems. 3. The caregiver is more ill than the client. 4. The caregiver is experiencing emotional stress. Correct Answer: 4 Rationale 1: There is no indication the caregiver has an underlying health problem such as a communicable disease. Rationale 2: There is no indication the caregiver has an underlying health problem such as uncared for health problems. Rationale 3: There is no indication the caregiver is more ill than the client. Rationale 4: Emotional health affects health in several ways. Stress affects the immune system, leading to increased susceptibility to infections. During periods of stress or change, the individual is less likely to adhere to positive health behaviors. Global Rationale: Emotional health affects health in several ways. Stress affects the immune system, leading to increased susceptibility to infections. During periods of stress or change, the individual is less likely to adhere to positive health behaviors. There is no indication the caregiver has an underlying health problem such as a communicable disease, uncared for health problems, or is more ill than the client. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.3: Identify factors affecting psychosocial health. Question 18 Type: MCSA A client tells the nurse, “I want to make sure my children have every possible opportunity to complete their education.” The nurse realizes this client’s philosophy on education will influence which aspect of her children’s health?

1. Attempt to meet immediate needs. 2. Help to elevate self-esteem. 3. Ongoing family disturbances. 4. Can lead to mental illness. Correct Answer: 2 Rationale 1: Focus on immediate needs is seen more in those individuals from lower socioeconomic groups. This is not associated with an increased emphasis and achievement of educational goals. Rationale 2: The higher the income, the more likely that individuals and families will achieve higher levels of education. The advantage contributes to the feelings of high self-worth and high self-esteem. Rationale 3: Individuals from lower socioeconomic groups face a focus on immediate needs. This focus promotes a sense of low self-esteem. Continued feelings of this nature may result in family disturbances. Rationale 4: Mental illness may be seen and remain untreated in lower socioeconomic groups as a result of ongoing focus on the meeting of immediate needs. This focus is often linked directly to a lack of education as seen in this population. Global Rationale: The higher the income, the more likely that individuals and families will achieve higher levels of education. The advantage contributes to the feelings of high self-worth and high self-esteem. In lower socioeconomic groups, energies are spent in attempts to achieve more immediate needs. This focus promotes a concern on those present issues, resulting in less health promotion and future focused goals. Family disturbances and mental illness are seen in lower socioeconomic groups. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5.3: Identify factors affecting psychosocial health. Question 19 Type: MCSA Because of statements made by the client during a physical assessment, the nurse believes the client is at risk for developing a major illness. Which of the following statements would cause the nurse to fear for this client? 1. “Look at that person’s pants! Don’t they realize how ugly they are?” 2. “That sounds like a good idea! I think I will try that at home.” 3. “I just love spending time outside. It energizes me!” 4. “I set aside a period of time each day for myself.”

Correct Answer: 1 Rationale 1: There are different characteristics and behaviors a person demonstrates that can be categorized along the continuum of being psychosocially healthy vs. being psychosocially unhealthy. Those who are unhealthy psychosocially are at risk for the onset of an illness. Those who are psychosocially unhealthy will demonstrate pessimism, will openly laugh at others, are a “challenge” to be around, have little fun, and are self-absorbed. Rationale 2: Individuals who are psychosocially healthy will demonstrate a zest for life and are adaptable to change. Rationale 3: Individuals who are psychosocially healthy will demonstrate respect for nature. Rationale 4: Individuals who are psychosocially healthy will demonstrate a zest for life, manage time well, and demonstrate coping skills. Global Rationale: There are different characteristics and behaviors a person demonstrates that can be categorized along the continuum of being psychosocially healthy vs. being psychosocially unhealthy. Those who are unhealthy psychosocially are at risk for the onset of an illness. Individuals who are psychosocially healthy will demonstrate a zest for life, manage time well, are adaptable to change, demonstrate coping skills, and respect nature. Those who are psychosocially unhealthy will demonstrate pessimism, will openly laugh at others, are a “challenge” to be around, have little fun, and are self-absorbed. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5.1: Describe psychosocial functioning. Question 20 Type: MCSA A client with hypertension stops into the clinic for his weekly blood pressure measurement. He tells the nurse that he is in a hurry because he started a new job and has to get back to work. Evidence that this client is responding to the new job in a stressful way would be: 1. Elevated blood pressure. 2. Respirations 16 and regular. 3. Temperature within normal limits. 4. Heart rate 86 and regular. Correct Answer: 1 Rationale 1: Physical signs of stress include elevated blood pressure, pulse, and respirations, dilated pupils, increased blood volume. and elevated blood glucose level.

Rationale 2: Respirations of 16 are within normal limits for an adult. Rationale 3: Normal body temperature does not indicate a stressful condition. Rationale 4: Heart rate of 86 is within normal limits for an adult. Global Rationale: Physical signs of stress include elevated blood pressure, pulse, and respirations, dilated pupils, increased blood volume, and elevated blood glucose level. Respirations of 16 are within normal limits for an adult. Normal body temperature does not indicate a stressful condition. Heart rate of 86 is within normal limits for an adult. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1: Describe psychosocial functioning. Question 21 Type: MCSA The nurse is assessing a client’s spiritual and belief patterns and is currently asking the client about participation in organized religion. The nurse is on which step of the HOPE assessment with this client? 1. H 2. O 3. P 4. E Correct Answer: 2 Rationale 1: H is for spiritual resources. Rationale 2: O is for participation in organized religion. Rationale 3: P is for personal spiritual practices. Rationale 4: E is for effects of healthcare and end-of-life issues. Global Rationale: The pneumonic HOPE is described as: H for spiritual resources, O for participation in organized religion, P for personal spiritual practices, and E for effects of healthcare and end-of-life issues. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 22 Type: MCSA A client is admitted to the psychiatric unit with complaints consistent with an anxiety disorder. During the assessment the nurse learns a client has a history of asthma and arthritis. Which of the following should the nurse do with this information? 1. Begin the respiratory assessment. 2. Begin the musculoskeletal status assessment. 3. Begin a review of the client’s current medications. 4. Begin the psychosocial assessment. Correct Answer: 4 Rationale 1: There is no indication the client is currently experiencing respiratory compromise, so the assessment of this system is not an immediate concern. Rationale 2: Although the patient has a history of arthritis there is no indication that the client is experiencing immediate concerns related to the musculoskeletal system. Rationale 3: A review of the client’s current medications will be included in the admission assessment but are not an immediate need. Rationale 4: The client in the question is being admitted for concerns related to an anxiety disorder. The admitting issues take priority in the collection of data. Some physical problems have associated or underlying psychosocial problems. Examples of these physical problems include arthritis and asthma. The nurse should spend time on the psychosocial assessment with this client. Global Rationale: The client in the question is being admitted for concerns related to an anxiety disorder. The admitting issues take priority in the collection of data. Some physical problems have associated or underlying psychosocial problems. Examples of these physical problems include arthritis and asthma. The nurse should spend time on the psychosocial assessment with this client. There is no indication the client is currently experiencing respiratory compromise so the assessment of this system is not an immediate concern. Although the patient has a history of arthritis there is no indication that the client is experiencing immediate concerns related to the musculoskeletal system. A review of the client’s current medications will be included in the admission assessment but are not immediate. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.3: Identify factors affecting psychosocial health.

Question 23 Type: MCSA The nurse is concerned that a client is having a problem with self-concept. Which of the following statements would cause the nurse to have this concern? 1. “I never have any fun.” 2. “I am the oldest in the family.” 3. “I think I’m pretty much outgoing.” 4. “At times I like to be alone.” Correct Answer: 1 Rationale 1: There are a variety of questions that can be asked to assess a client’s self concept. The client’s response provides information to the nurse about problems or concerns with this characteristic. Clients who are unable to explain a social life or who do not have any fun may be depressed or out of touch with reality. Rationale 2: Birth order in the family is not implicated in the client. Rationale 3: An outgoing client is not at high risk for problems with self-concept. Rationale 4: Occasional desire to be alone does not indicate a problem with self-concept. Global Rationale: There are a variety of questions that can be asked to assess a client’s self-concept. The client’s response provides information to the nurse about problems or concerns with this characteristic. Clients who are unable to explain a social life or who do not have any fun may be depressed or out of touch with reality. Birth order in the family is not implicated in the client. An outgoing client is not at high risk for problems with selfconcept. Occasional desire to be alone does not indicate a problem with self-concept. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 24 Type: MCSA The nurse believes a client is having difficulty coping with current illness and hospitalization. Which of the following assessment questions would best help the nurse identify the client’s coping ability? 1. Who is your closest friend? 2. What social groups do you belong to?

3. What is your birth order in your family? 4. Who do you call when you need help? Correct Answer: 4 Rationale 1: Questions about friends assess the client’s Roles & Relationships. Rationale 2: Questions about social groups assess the client’s Roles & Relationships. Rationale 3: Questions about birth order focus on the client’s Family History. Rationale 4: Questions that are helpful to gather additional information about a client’s stress and coping mechanisms include: What do you do for relaxation? For recreation? What is your greatest source of comfort when you are feeling upset? Who do you call for help? What is your current level of stress? Global Rationale: Questions that are helpful to gather additional information about a client’s stress and coping mechanisms include: What do you do for relaxation? For recreation? What is your greatest source of comfort when you are feeling upset? Who do you call for help? What is your current level of stress? Questions about friends and social groups assess the client’s Roles & Relationships, whereas questions about birth order focus on the client’s Family History. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 25 Type: MCSA During an assessment the nurse observes the client jumping from one idea to another, unable to completely answer any of the assessment questions. The nurse recognizes this speech pattern as being: 1. Circumlocution. 2. Flight of ideas. 3. Neologisms. 4. Echolalia. Correct Answer: 2 Rationale 1: Circumlocution means the client is demonstrating numerous digressions. Rationale 2: The speech pattern where thoughts and ideas jump is termed flight of ideas.

Rationale 3: Neologisms are the coining of new words that have significance to the client. Rationale 4: Echolalia is the constant repetition of words or phrases that the client hears others say. Global Rationale: The speech pattern where thoughts and ideas jump is termed flight of ideas. Circumlocution means the client is demonstrating numerous digressions. Neologisms are the coining of new words that have significance to the client. Echolalia is the constant repetition of words or phrases that the client hears others say. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5.1: Describe psychosocial functioning. Question 26 Type: MCSA A client voices concerns about becoming pregnant. The client reports her mother had a history of schizophrenia. The client is fearful of having a child with the same disorder. What is the best initial response by the nurse? 1. “Schizophrenia is a genetic disorder so you are right to be very concerned.” 2. “Your family history does increase the risk factors but there are other variables to be considered.” 3. “Schizophrenia should not be a significant concern for you.” 4. “You should consider being tested before becoming pregnant.” Correct Answer: 2 Rationale 1: Telling the patient to be very concerned does not present the maximum amount of information. Rationale 2: Schizophrenia does have genetic links. Individuals having a family history have a greater incidence of also displaying the disorder. There are, however, other variables such as environment that should be considered. Rationale 3: Advising the client that it should not be a significant concern both downplays the actual risk and minimizes the client’s concerns. Rationale 4: There are no tests that can be run for this disease. Global Rationale: Schizophrenia does have genetic links. Individuals having a family history have a greater incidence of also displaying the disorder. There are, however, other variables such as environment that should be considered. Telling the patient to be very concerned does not present the maximum amount of information. Advising the client that it should not be a significant concern both downplays the actual risk and minimizes the client’s concerns. There are no tests that can be run for this disease. Cognitive Level: Analyzing

Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.2: Define psychosocial health. Question 27 Type: MCSA A client is seen at the ambulatory care clinic for a routine physical examination. During the examination, the client discusses having gained more than 25 pounds in the past year despite not changing the level of activity or dietary intake. What response by the nurse is indicated? 1. “You must be eating more than you realize.” 2. “Do you think increasing exercise might help you with your excessive weight gain?” 3. “Tell me about any changes in your stress levels.” 4. “This weight gain is likely the result of aging.” Correct Answer: 3 Rationale 1: Telling the client that he is indeed eating more than realized is confrontational. Rationale 2: Encouraging the client to increase exercise may be beneficial but the nurse must first assess for potential causes. Rationale 3: Periods of stress may result in obesity. In addition, some individuals will use comfort foods during periods of stress. Rationale 4: Many people do gain weight as they age but there is no indication that this is correct for this individual. Global Rationale: Periods of stress may result in obesity. In addition, some individuals will use comfort foods during periods of stress. Telling the client that he is indeed eating more than realized is confrontational. Encouraging the client to increase exercise may be beneficial but the nurse must first assess for potential causes. Many people do gain weight as they age but there is no indication that this is correct for this individual. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3: Identify factors affecting psychosocial health. Question 28 Type: MCSA

A client is admitted to the psychiatric care unit. During the admission process, while the nurse is explaining the use of the call light the client smiles and says, “Apples, corn, dogs, my foot.” The nurse correctly documents the client is demonstrating which of the following speech patterns? 1. Neologisms 2. Clanging 3. Word salad 4. Echolalia Correct Answer: 3 Rationale 1: Neologisms refer to the coining of new words. Rationale 2: Clanging refers to engaging in a conversation in which the words rhyme. Rationale 3: The grouping of words together in a manner that does not make sense is known as word salad. Rationale 4: Echolalia is the constant repetition of words by the client that have been said by others. Global Rationale: The grouping of words together in a manner that does not make sense is known as word salad. Neologisms refer to the coining of new words. Clanging refers to engaging in a conversation in which the words rhyme. Echolalia is the constant repetition of words by the client that have been said by others. Cognitive Level: Understanding Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.1: Identify factors affecting psychosocial health. Question 29 Type: MCMA The nurse is attempting to assess a client who appears agitated. The client believes the nurse is trying to hurt him and is not cooperating with the nurse. What actions by the nurse are indicated? Standard Text: Select all that apply. 1. Advise the client that the healthcare provider will be contacted unless the client complies. 2. Restrain the client using leather restraints. 3. Speak to the client in a calm voice. 4. Explain actions to the client as they are done.

5. Medicate the client. Correct Answer: 3,4 Rationale 1: Advise the client that the healthcare provider will be contacted unless the client complies. Telling the client that the healthcare provider will be called in this manner may be viewed as threatening. This action may further upset the client. Rationale 2: Restrain the client using leather restraints. The use of restraints in the psychiatric setting is limited. Restraints should be a last resort and only indicated when the client may harm himself or another individual. There is no indication either of these criteria has been met. Rationale 3: Speak to the client in a calm voice. Speaking in a calm voice may help to diffuse the situation and relax the client. Rationale 4: Explain actions to the client as they are done. Explaining activities to the client may help to reduce the fears being experienced by the client. Rationale 5: Medicate the client. The administration of medications simply to quiet the client is considered a form of chemical restraint. In addition, it is beyond the scope of practice to medicate the client without specific orders from the healthcare provider. Global Rationale: Telling the client that the healthcare provider will be called in this manner may be viewed as threatening. This action may further upset the client. The use of restraints in the psychiatric setting is limited. Restraints should be a last resort and indicated only when the client may harm himself or another individual. There is no indication either of these criteria has been met. Speaking in a calm voice may help to diffuse the situation and relax the client. Explaining activities to the client may help to reduce the fears being experienced by the client. The administration of medications simply to quiet the client is considered a form of chemical restraint. In addition, it is beyond the scope of practice to medicate the client without specific orders from the healthcare provider. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health. Question 30 Type: MCSA A client has presented to the ambulatory care clinic with complaints of back pain, nausea, and fatigue. When the nurse questions the client about recent stressors the client becomes irritated and states, “I am sick. Why are you asking me about all of this stress stuff?” Which of the following responses by the nurse is most appropriate? 1. “Stress can impact our body by producing a variety of symptoms.” 2. “Your nausea and fatigue are most often related to an overabundance of stress in life.”

3. “Asking about stress is required for every client.” 4. “We all have stress and I need to see how much you have.” Correct Answer: 1 Rationale 1: Stress is associated with a variety of physical ailments, including back pain, nausea, and fatigue. The nurse has a responsibility to provide education to the client concerning the reasons behind the questions being asked. Rationale 2: The final diagnosis as to the cause of the ailments being reported has not been completed. It is premature for the nurse to equate an overabundance of stress to the physical concerns reported. Rationale 3: Stress assessment may be a requirement for many data collections but this does not provide an adequate response to the client. Rationale 4: Telling the client that all people have stress downplays the client’s individual needs and is inappropriate. Global Rationale: Stress is associated with a variety of physical ailments, including back pain, nausea, and fatigue. The nurse has a responsibility to provide education to the client concerning the reasons behind the questions being asked. The final diagnosis as to the cause of the ailments being reported has not been completed. It is premature for the nurse to equate an overabundance of stress to the physical concerns reported. Stress assessment may be a requirement for many data collections but this does not provide an adequate response to the client. Telling the client that all people have stress downplays the client’s individual needs and is inappropriate. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3: Identify factors affecting psychosocial health.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 6 Question 1 Type: HOTSPOT The nursing instructor is demonstrating, to a group of nursing students, the proper technique for assessing a client for fremitus. Which part of the hand will the instructor use to demonstrate proper technique?

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand. Global Rationale: Cognitive Level: Remembering Client Need: Health Promotion and Maintenance

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment. Question 2 Type: MCSA The nurse is preparing to assess the thorax of an infant using the assessment technique of direct percussion. To correctly perform this assessment the nurse will use the: 1. hyperextended middle finger of the nondominant hand. 2. closed fist of dominant hand. 3. palm of the nondominant hand. 4. fingertips of the dominant hand. Correct Answer: 4 Rationale 1: Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor. Rationale 2: Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand. Rationale 3: The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion. Rationale 4: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess thorax of an infant and also to assess the sinuses of an adult client. Global Rationale: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess the thorax of an infant and also to assess the sinuses of an adult client. Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor. Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand. The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment. Question 3 Type: MCSA During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which of the following would be the best action for the nurse to take next? 1. Document this as abnormal. 2. Wet the chest hair before auscultating the chest. 3. Place the diaphragm on top of the client’s shirt. 4. Switch from the diaphragm to the bell. Correct Answer: 2 Rationale 1: The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal. Rationale 2: Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the client’s chest before auscultation. Rationale 3: Auscultating lung sounds over the client’s clothing will increase rather than decrease friction sounds. Rationale 4: Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them won’t make a difference. Global Rationale: Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the client’s chest before auscultation. The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal. Auscultation of lung sounds over the client’s clothing will increase rather than decrease friction sounds. Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them won’t make a difference. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment. Question 4

Type: MCSA The nursing instructor is observing a student nurse who is performing abdominal palpation on an adult client. In order to assess organs that lie deep within the abdominal cavity (e.g., kidneys, spleen), the student nurse should press on the client’s abdomen using which of the following techniques? 1. Downward pressure of 1–2 cm using the finger pads 2. Side to side pressure of ½–1 cm using the finger pads 3. Downward pressure of 2–4 cm using the palmar surface of the fingers 4. Light pressure using the base of the fingers (metacarpophalangeal joints) Correct Answer: 3 Rationale 1: Downward depression of 1–2 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen. Rationale 2: Side-to-side palpation of ½–1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node). Rationale 3: Deep palpation of 2–4 cm (3/4–1½ inches) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward. Rationale 4: Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus. Global Rationale: Deep palpation of 2–4 cm (3/4–1½ inches) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward. Downward depression of 1–2 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen. Side-to-side palpation of ½–1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node). Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment. Question 5 Type: MCSA The nurse is preparing to assess a client’s abdomen. Which of the following sequences will the nurse use to assess this body area? 1. Percussion, Palpation, Auscultation, Inspection 2. Auscultation, Inspection, Palpation, Percussion 3. Inspection, Palpation, Percussion, Auscultation 4. Inspection, Auscultation, Percussion, Palpation Correct Answer: 4 Rationale 1: Assessement always begins with inspection. Percussing and palpating the abdomen before auscultating could alter the natural sounds of the abdomen. Rationale 2: Assessment always begins with inspection. In the assessment of the abdomen, inspection is followed by auscultation. Rationale 3: Inspection, palpation, percussion, and auscultation is the usual order of assessment except when assessing the abdomen. Rationale 4: The nurse alters the usual order of the four basic techniques of assessment when examining the abdomen. The correct order for abdominal assessment is inspection, auscultation, percussion, and finally palpation. Percussing and palpating before auscultating could alter the natural sounds of the abdomen. Global Rationale: The nurse alters the usual order of the four basic techniques of assessment when examining the abdomen. The correct order for abdominal assessment is inspection, auscultation, percussion, and finally palpation. Percussing and palpating before auscultating could alter the natural sounds of the abdomen. Assessment always begins with inspection. In the assessment of the abdomen, inspection is followed by auscultation, then percussion, and finally palpation. Inspection, palpation, percussion, and auscultation is the usual order of assessment except when assessing the abdomen. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment. Question 6 Type: MCSA

The nurse is inspecting a client’s chest and upper extremities. Which of the following would be the appropriate method for the nurse to assess these body areas? 1. Examine the right arm, the chest, and then the left arm. 2. Examine the left arm, the chest, and then the right arm. 3. Examine the left arm, the right arm, and then the chest. 4. Examine the chest and examine the arms at the conclusion of the exam as the client is re-dressing. Correct Answer: 3 Rationale 1: The nurse should compare the left and right arms before moving to the chest. Rationale 2: The nurse should compare the left and right arms before moving to the chest. Rationale 3: Inspection begins with a survey of the client’s appearance and a comparison of the right and left sides of the body, which should be nearly symmetrical. The nurse should compare the left and right arms before moving to the chest. Rationale 4: The nurse should give the client privacy at the conclusion of the physical assessment to re-dress. Global Rationale: Inspection begins with a survey of the client’s appearance and a comparison of the right and left sides of the body, which should be nearly symmetrical. The nurse should compare the left and right arms before moving to the chest. The nurse should give the client privacy at the conclusion of the physical assessment to re-dress. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment. Question 7 Type: MCSA A client has a reddened area on the left forearm. Which of the following assessment techniques should the nurse use to assess this area? 1. Percussion 2. Light palpation 3. Moderate palpation 4. Deep palpation

Correct Answer: 2 Rationale 1: Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid. Rationale 2: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Rationale 3: Moderate palpation is used to assess most of the other structures of the body. Rationale 4: Deep palpation is used to assess an organ that lies deep within a body cavity. Global Rationale: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid. Moderate palpation is used to assess most of the other structures of the body. Deep palpation is used to assess an organ that lies deep within a body cavity. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment. Question 8 Type: MCSA While auscultating a client’s lungs, the nurse identifies more than one sound. Which of the following should the nurse do? 1. Obtain a stethoscope with longer tubing. 2. Ask another nurse to listen to the lung sounds. 3. Hold the stethoscope tubing while listening to the lung sounds. 4. Close the eyes and focus on one sound at a time. Correct Answer: 4 Rationale 1: Long tubing on a stethoscope can distort sounds; this would not help the nurse identify chest sounds. Rationale 2: Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard. Rationale 3: Touching the stethoscope tubing can cause additional sounds and should be avoided. Rationale 4: Closing the eyes and concentrating on each sound may help the nurse focus on the sound.

Global Rationale: Closing the eyes and concentrating on each sound may help the nurse focus on the sound. Long tubing on a stethoscope can distort sounds; this would not help the nurse identify chest sounds. Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard. Touching the stethoscope tubing can cause additional sounds and should be avoided. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment. Question 9 Type: MCSA The nurse is assessing a client’s right lower extremity and during inspection notes an area of redness. In order to assess the temperature of the client’s skin, the nurse should use which part of the hand? 1. Fingertips 2. Metacarpophalgeal joints 3. Dorsal surface 4. Ulnar surface Correct Answer: 3 Rationale 1: The fingertips are used for identifying underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus. Rationale 2: The metacarpophalgeal joint area of the hand is used to assess for vibration, or fremitus. Rationale 3: The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature. Rationale 4: The ulnar surface of the hand is also used to assess for fremitus. Global Rationale: The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature. The fingertips are used for identifying underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus. The metacarpophalgeal joint area of the hand is used to assess for vibration, or fremitus. The ulnar surface of the hand is also used to assess for fremitus. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment. Question 10 Type: MCSA The nurse is preparing to percuss the lower lobes of a client’s lungs. The percussion technique appropriate for this body area would be: 1. direct percussion. 2. blunt percussion. 3. indirect percussion. 4. any of the percussion techniques. Correct Answer: 3 Rationale 1: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to examine the thorax of an infant and to assess the sinuses of an adult. Rationale 2: Blunt percussion involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the dominant hand. A closed fist of the dominant hand is used to deliver the blow. Rationale 3: Percussion of the lungs is done using indirect percussion, as it produces sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most commonly used. Rationale 4: In order to gain accurate objective information, it is important for the nurse to choose the proper assessment technique, which in this situation is indirect percussion. Global Rationale: Percussion of the lungs is done using indirect percussion, as it produces sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most commonly used. Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to examine the thorax of an infant and to assess the sinuses of an adult. Blunt percussion involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the dominant hand. A closed fist of the dominant hand is used to deliver the blow. This method is used for assessing pain and tenderness in the gallbladder, liver, and kidneys. In order to gain accurate objective information, it is important for the nurse to choose the proper assessment technique, which in this situation is indirect percussion. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 11 Type: MCMA The nurse is teaching a group of health assistants about the stethoscope. Which of the following statements about the stethoscope will the nurse include in this teaching session? Standard Text: Select all that apply. 1. The stethoscope works by blocking out environmental sounds. 2. Short tubing provides the listener with the most accurate sounds. 3. The bell of the stethoscope is used for high-pitched sounds, such as lung sounds. 4. Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection. 5. The binaurals should fit snugly in the ears. Correct Answer: 1,2,5 Rationale 1: The stethoscope works by blocking out environmental sounds. The stethoscope works by blocking out environmental sounds; it does not amplify sounds in the body. Rationale 2: Short tubing provides the listener with the most accurate sounds. Short tubing provides the listener with the most accurate sounds; longer tubing may distort sound. Rationale 3: The bell of the stethoscope is used for high-pitched sounds, such as lung sounds. The bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart murmur. The diaphragm is used for high-pitched sounds, such as normal heart sounds and lung sounds. Rationale 4: Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection. The stethoscope should be cleaned after examining a client to prevent the spread of infection. Rationale 5: The binaurals should fit snugly in the ears. The binaurals should fit snugly yet comfortably in the ears. Global Rationale: The stethoscope works by blocking out environmental sounds; it does not amplify sounds in the body. Short tubing provides the listener with the most accurate sounds; longer tubing may distort sound. The binaurals should fit snugly yet comfortably in the ears. The bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart murmur. The diaphragm is used for high-pitched sounds, such as normal heart sounds and lung sounds. The stethoscope should be cleaned after examining a client to prevent the spread of infection. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.2: Explain the purpose of equipment required to perform physical assessment.

Question 12 Type: MCMA The nurse uses the otoscope in the physical assessment of a client. The nurse understands that this instrument is used to: Standard Text: Select all that apply. 1. Inspect the nose. 2. Funnel light into the ear canal. 3. Inspect the internal structures of the eye. 4. Assess pulses that are not palpable. 5. Detect fungal infections of the skin. Correct Answer: 1,2 Rationale 1: Inspect the nose. The otoscope can be used to inspect the nose, by inserting a wide speculum into the client’s naris. Rationale 2: Funnel light into the ear canal. The otoscope funnels light into the ear canal to allow the examiner to inspect the tympanic membrane (eardrum) as well as the ear canal itself. Rationale 3: Inspect the internal structures of the eye. The ophthalmoscope is used to inspect the internal structure of the eye. Rationale 4: Assess pulses that are not palpable. The Doppler uses ultrasonic waves to detect pulses that are difficult to palpate. Rationale 5: Detect fungal infections of the skin. A Wood’s lamp produces a black light that emits a yellowgreen fluorescence on skin in the presence of a fungal infection. Global Rationale: The otoscope can be used to inspect the nose, by inserting a wide speculum into the client’s naris. The otoscope funnels light into the ear canal to allow the examiner to inspect the tympanic membrane (eardrum) as well as the ear canal itself. The ophthalmoscope is used to inspect the internal structure of the eye. The Doppler uses ultrasonic waves to detect pulses that are difficult to palpate. A Wood’s lamp produces a black light that emits a yellow-green fluorescence on skin in the presence of a fungal infection. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2: Explain the purpose of equipment required to perform a complete physical assessment.

Question 13 Type: MCSA The nurse is using an ophthalmoscope to assess the optic disc in a client. The nurse would suspect hemorrhage of the optic disc is present when which of the following colors is visualized through the red-free filter of the ophthalmoscope? 1. Green 2. Black 3. Red 4. Yellow Correct Answer: 2 Rationale 1: The color green is not an expected finding of fundoscopic examination of the eye. Rationale 2: The red-free filter is used to examine the optic disc for hemorrhage. This filter shines a green beam into the eye and if hemorrhage is present, the disc will appear black. Rationale 3: The color red is observed as the red reflex; light reflecting off the retina when a bright white light is shined through the pupil. This is a normal finding. Rationale 4: Yellow is the color of a normal optic disc. This is elicited using the bright white light of the ophthalmoscope. Global Rationale: The red-free filter is used to examine the optic disc for hemorrhage. This filter shines a green beam into the eye and if hemorrhage is present, the disc will appear black. The color green is not an expected finding of fundoscopic examination of the eye. The color red is observed as the red reflex; light reflecting off the retina when a bright white light is shined through the pupil. This is a normal finding. Yellow is the color of a normal optic disc. This is elicited using the bright white light of the ophthalmoscope. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2: Explain the purpose of equipment required to perform a complete physical assessment. Question 14 Type: HOTSPOT The nursing instructor is teaching a group of nursing students the correct assessment of normal heart sounds. Draw an arrow on the part of the stethoscope that should be used by the nursing student to auscultate normal heart sounds.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2: Explain the purpose of equipment required to perform a complete physical assessment. Question 15 Type: MCSA The nurse is about to perform a physical assessment on an adult client. Before beginning this phase of the client’s health assessment, the nurse should first: 1. Provide a gown for the client to change into. 2. Explain to the client what will happen during the examination. 3. Obtain a written consent. 4. Wash hands in the presence of the client. Correct Answer: 2 Rationale 1: The client may need to change into a gown in order for the nurse to perform the assessment; however, the nurse should first explain what will be happening before asking the client to change clothing.

Rationale 2: The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a client’s anxiety and enlists the client’s cooperation with the assessment. Rationale 3: Obtaining a written consent is not necessary, unless an invasive procedure will be performed. Rationale 4: Handwashing should be performed just before the nurse begins to touch the client and after a full explanation of the process is given and again at the completion of the physical assessment. Global Rationale: The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a client’s anxiety and enlists the client’s cooperation with the assessment. The client may need to change into a gown in order for the nurse to perform the assessment; however, the nurse should first explain what will be happening before asking the client to change clothing. Obtaining a written consent is not necessary, unless an invasive procedure will be performed. Handwashing should be performed just before the nurse begins to touch the client and after a full explanation of the process is given. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when performing physical assessment. Question 16 Type: MCSA The nurse is assessing an anxious-appearing client who is experiencing abdominal pain. The nurse should use which of the following techniques to put the client at ease when assessing the client’s abdomen? 1. Palpate known painful areas first. 2. Touch each area lightly before applying deeper palpation. 3. Perform the exam as quickly as possible. 4. Refrain from conversation during the assessment. Correct Answer: 2 Rationale 1: Known painful areas are usually the last area to be palpated as pain and tenderness cause the client to tense. Rationale 2: Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction. Rationale 3: Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction.

Rationale 4: The client will be more relaxed if the nurse talks during the assessment, explaining each movement in advance. The nurse often needs to ask the client questions during the assessment to gain a broader knowledge of the client’s health. Global Rationale: Known painful areas are usually the last area to be palpated as pain and tenderness cause the client to tense. Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction. The nurse should proceed slowly, using smooth, deliberate movements during the exam. The client will be more relaxed if the nurse talks during the assessment, explaining each movement in advance. The nurse often needs to ask the client questions during the assessment to gain a broader knowledge of the client’s health. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when performing physical assessment. Question 17 Type: MCSA 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. Correct Answer: 2 Rationale 1: The nurse must never attempt to influence or coerce the client to agree to a procedure; giving the client a break and then resuming the assessment could be viewed as a form of coercion. Rationale 2: The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused. Rationale 3: It is not necessary for another nurse to witness a client’s refusal of care. The nurse should document what was done and what the client refused. Rationale 4: Allowing a family member to be present during the assessment may be helpful, but the client’s wishes (refusal) must be respected. Global Rationale: The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused. The nurse must never attempt to influence or coerce the client to agree to a

procedure; giving the client a break and then resuming the assessment could be viewed as a form of coercion. It is not necessary for another nurse to witness a client’s refusal of care. The nurse should document what was done and what the client refused. Allowing a family member to be present during the assessment may be helpful, but the client’s wishes (refusal) must be respected. Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when performing physical assessment. Question 18 Type: MCMA The nurse is preparing to perform a complete health assessment on a client. Which of the following activities should the nurse perform just prior to this examination? Standard Text: Select all that apply. 1. Put on nonsterile gloves. 2. Provide an opportunity for the client to void. 3. Wash hands in the presence of the client. 4. Turn on soft music to relax the client. 5. Lower the lights in the room to prevent glare. Correct Answer: 2,3 Rationale 1: Put on nonsterile gloves. Gloves are needed only if the nurse may come into contact with the client’s blood or body fluids, such as during the assessment of the genitalia or anus. Rationale 2: Provide an opportunity for the client to void. The client should be given an opportunity to void prior to physical assessment. This helps the client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs. Rationale 3: Wash hands in the presence of the client. The nurse should always perform handwashing in the presence of the client prior to physical contact. This demonstrates that the nurse is providing for the client’s safety and also protects the nurse. Rationale 4: Turn on soft music to relax the client. The assessment should take place in a quiet environment in order for the nurse to correctly identify sounds and their characteristics. Rationale 5: Lower the lights in the room to prevent glare. The room should be brightly lit to facilitate good visibility.

Global Rationale: The client should be given an opportunity to void prior to physical assessment. This helps the client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs. The nurse should always perform handwashing in the presence of the client prior to physical contact. This demonstrates that the nurse is providing for the client’s safety and also protects the nurse. Gloves are needed only if the nurse may come into contact with the client’s blood or body fluids, such as during the assessment of the genitalia or anus. The assessment should take place in a quiet environment in order for the nurse to correctly identify sounds and their characteristics. The room should be brightly lit to facilitate good visibility. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when performing physical assessment. Question 19 Type: MCSA The nurse is assessing a client for hepatomegaly by percussing over the liver. The nurse would expect to hear which of the following sounds when percussing the liver? 1. Loud, low-pitched 2. Soft, high-pitched 3. Drum-like 4. Abnormally loud Correct Answer: 2 Rationale 1: Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines. Rationale 2: Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver. Rationale 3: Resonance is a loud, low-pitched tone of normal findings over the lungs. Rationale 4: Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs. Global Rationale: Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver. Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines. Resonance is a loud, low-pitched tone of normal findings over the lungs. Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs. Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment. Question 20 Type: MCSA 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. Asymmetry of the client’s smile 2. Grimacing with movement 3. Talking in a loud voice 4. Inability to follow directions Correct Answer: 1 Rationale 1: Asymmetry of facial expressions is a cue that the client may be experiencing a neurological problem and the nurse should perform an assessment of the cranial nerves. Rationale 2: Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal problem. Rationale 3: Talking in a loud voice may cue the nurse that the client has hearing loss. Rationale 4: The client’s inability to follow directions may also be the result of a hearing loss. Global Rationale: Asymmetry of facial expressions is a cue that the client may be experiencing a neurological problem and the nurse should perform an assessment of the cranial nerves. Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal problem. Talking in a loud voice may cue the nurse that the client has hearing loss. The client’s inability to follow directions may also be the result of a hearing loss. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment. Question 21 Type: MCSA The nurse is performing an abdominal assessment and has just completed inspection. Which of the following techniques would the nurse correctly choose to use next in this assessment?

1. Percussion 2. Palpation 3. Transillumination 4. Auscultation Correct Answer: 4 Rationale 1: Percussing before auscultating the abdomen may alter the natural sounds of the abdomen. Rationale 2: Palpation prior to auscultation of the abdomen could alter the natural sounds; therefore auscultation is performed immediately following inspection. Rationale 3: Transillumination of the abdomen is not part of the abdominal assessment. Rationale 4: Auscultation of the abdomen is the assessment technique that follows inspection. It is important to listen before touching to avoid altering a client’s natural abdominal sounds. Global Rationale: Auscultation of the abdomen is the assessment technique that follows inspection. It is important to listen before touching to avoid altering a client’s natural abdominal sounds. Percussing before auscultating the abdomen may alter the natural sounds of the abdomen. Palpation prior to auscultation of the abdomen could alter the natural sounds, therefore auscultation is performed immediately following inspection. Transillumination of the abdomen is not part of the abdominal assessment Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment. Question 22 Type: MCSA 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. Check the pressure applied to the probe. 2. Add more gel to the end of the probe. 3. Immediately inform the healthcare provider. 4. Send the equipment for repair. Correct Answer: 1

Rationale 1: Heavy pressure to the probe should be avoided because it may impede blood flow—the probe should be placed gently against the client’s skin, over the artery to be auscultated. Rationale 2: A small amount of gel is applied to the end of the Doppler probe to eliminate interference. Rationale 3: Informing the healthcare provider may be premature until it is determined that the Doppler probe is being used correctly. Rationale 4: Sending the equipment for repair is premature at this time. Global Rationale: Heavy pressure to the probe should be avoided because it may impede blood flow—the probe should be placed gently against the client’s skin, over the artery to be auscultated. A small amount of gel is applied to the end of the Doppler probe to eliminate interference. Informing the healthcare provider may be premature until it is determined that the Doppler probe is being used correctly. Sending the equipment for repair is premature at this time. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment. Question 23 Type: MCSA A client has a visible pulsation in the middle of his abdomen. The assessment technique the nurse should use to assess this pulsation is: 1. Percussion. 2. Light palpation. 3. Moderate palpation. 4. Deep palpation. Correct Answer: Rationale 1: Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid. Rationale 2: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Rationale 3: With moderate palpation, the nurse uses the palmar surface of the fingers to determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present.

Rationale 4: Deep palpation is used to assess an organ that lies deep within a body cavity. Global Rationale: With moderate palpation, the nurse uses the palmar surface of the fingers to determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present. Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid. Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Deep palpation is used to assess an organ that lies deep within a body cavity. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment. Question 24 Type: MCSA The nurse is conducting an assessment of a client with right lower quadrant abdominal pain. Which of the following should the nurse do when palpating the abdomen of this client? 1. Assess the painful area first using moderate palpation. 2. Assess the painful area last using deep palpation. 3. Assess the painful area last using light palpation. 4. Assess the painful area first using deep palpation. Correct Answer: 2 Rationale 1: Painful areas are not palpated first. Rationale 2: Known painful areas of the body are usually the last area to be palpated. The assessment of structures of the abdomen requires moderate to deep palpation. Rationale 3: Light palpation is used to evaluate surface characteristics, not the structures of the abdomen. Rationale 4: While deep palpation is the appropriate technique, the painful area is examined last. Global Rationale: Known painful areas of the body are usually the last area to be palpated. The assessment of structures of the abdomen requires moderate to deep palpation. Painful areas are not palpated first. Light palpation is used to evaluate surface characteristics, not the structures of the abdomen. While deep palpation is the appropriate technique, the painful area is examined last. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment. Question 25 Type: MCSA While percussing a client’s lung area the nurse notes a flat tone. This tone would indicate: 1. The nurse is percussing over a bone. 2. A normal finding. 3. The lungs are solidified. 4. Air is trapped in the lungs. Correct Answer: 1 Rationale 1: Flat tones are high-pitched, soft tones of short duration and are the result of percussion over solid tissue such as muscle or bone. Rationale 2: Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of long duration known as resonance. Rationale 3: Solidified areas of the lung will produce dullness on percussion, a high-pitched soft tone of short duration. Rationale 4: Percussion over the lung where air has become trapped produces an abnormally loud, low tone of longer duration than resonance. Global Rationale: Flat tones are high-pitched, soft tones of short duration are the result of percussion over solid tissue such as muscle or bone. Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of long duration known as resonance. Solidified areas of the lung will produce dullness on percussion, a high-pitched soft tone of short duration. Percussion over the lung where air has become trapped produces an abnormally loud, low tone of longer duration than resonance. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment. Question 26 Type: MCSA The nurse is unable to palpate a client’s pedal pulses. Which of the following items will the nurse use to help locate this client’s pedal pulses?

1. Stethoscope 2. Doppler 3. Transilluminator 4. Goniometer Correct Answer: 2 Rationale 1: A stethoscope is used to auscultate body sounds such as blood pressure and heart, lung, and abdominal sounds. Rationale 2: The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope, such as peripheral pulses. Rationale 3: A transilluminator detects blood, fluid, or masses in body cavities. Rationale 4: A Goniometer is used to measure the degree of joint flexion and extension. Global Rationale: The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope, such as peripheral pulses. A stethoscope is used to auscultate body sounds such as blood pressure and heart, lung, and abdominal sounds. A transilluminator detects blood, fluid, or masses in body cavities. A goniometer is used to measure the degree of joint flexion and extension. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment. Question 27 Type: MCSA While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. What is the nurse’s next step? 1. Inform the client of “the abnormality.” 2. Stop the assessment and refer the client to the healthcare provider immediately. 3. Bring in another examiner to assess the finding. 4. Document the finding and reassess at the client’s next visit. Correct Answer: 3

Rationale 1: When the nurse identifies an unfamiliar finding, it is appropriate to consult with a colleague to assess the finding. Rationale 2: Informing the client of “the abnormality” may cause the client undue anxiety, as the finding may be a normal variant. Rationale 3: The nurse needs to complete the assessment before deciding on the urgency of referral to the health care provider, and this includes having a colleague assess the nurse’s unfamiliar finding. Rationale 4: The finding should be investigated at this visit, first by asking another examiner to assess the concern. Global Rationale: When the nurse identifies an unfamiliar finding, it is appropriate to consult with a colleague to assess the finding. Informing the client of “the abnormality” may cause the client undue anxiety, as the finding may be a normal variant. The nurse needs to complete the assessment before deciding on the urgency of referral to the healthcare provider, and this includes having a colleague assess the nurse’s unfamiliar finding. The finding should be investigated at this visit, first by asking another examiner to assess the concern. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment. Question 28 Type: MCSA The nurse is preparing to examine several clients in the clinic setting. Which of the following clients would need the greatest degree of special consideration during a physical examination? 1. 59-year old with flu symptoms 2. 3-year-old child in for a well check-up 3. 17-year old who complains of fatigue 4. 68-year old with chronic lung disease Correct Answer: 4 Rationale 1: A client ill with an acute condition such as a flu-like illness is not the same risk category as the older client with a chronic disease. Rationale 2: Assessment approaches and techniques may vary for children, but a 3-year old is not considered at the same risk potential as a client with a chronic respiratory illness. Rationale 3: Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but in general the position changes required during the complete health assessment should not be taxing on a teen.

Rationale 4: Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion. Global Rationale: Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion. A client ill with an acute condition such as a flu-like illness is not the same risk category as the older client with a chronic disease. Assessment approaches and techniques may vary for children, but a 3-year old is not considered at the same risk potential as a client with a chronic respiratory illness. Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but in general the position changes required during the complete health assessment should not be taxing on a teen. Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment. Question 29 Type: MCMA The nurse is preparing to assess an adult client who presents to the emergency room after falling down some steps at home. The client complains of left ankle pain and has open abrasions to the left knee and shin. Which of the following should the nurse incorporate into the physical assessment of this client? Standard Text: Select all that apply. 1. Wash hands in the presence of the client. 2. Put on nonsterile gloves to examine the client. 3. Ensure that the client has an empty bladder before beginning the physical assessment. 4. Instruct the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam. 5. Assess only the left lower extremity since this is the injured body part. Correct Answer: 1,2 Rationale 1: Wash hands in the presence of the client. The nurse should always perform handwashing prior to physical contact with a client. Rationale 2: Put on nonsterile gloves to examine the client. Because this client has open wounds, the nurse should wear gloves during the physical assessment to protect against blood-borne pathogens.

Rationale 3: Ensure that the client has an empty bladder before beginning the physical assessment. When the client’s abdomen will be examined, it is important to have the client empty the bladder to promote client comfort and facilitate the examination. It is not a priority in this situation. Rationale 4: Instruct the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam. The nurse should encourage the client to ask questions and offer comments during assessment. This helps the nurse gain accurate information and helps to relieve a client’s anxiety. Rationale 5: Assess only the left lower extremity since this is the injured body part. The nurse should always do a comparison of both sides of the body. Global Rationale: The nurse should always perform handwashing prior to physical contact with a client. Because this client has open wounds, the nurse should wear gloves during the physical assessment to protect against bloodborne pathogens. When the client’s abdomen will be examined, it is important to have the client empty the bladder to promote client comfort and facilitate the examination. It is not a priority in this situation. The nurse should encourage the client to ask questions and offer comments during assessment. This helps the nurse gain accurate information and helps to relieve a client’s anxiety. The nurse should always do a comparison of both sides of the body. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.5: Apply the principles of Standard Precautions in practice. Question 30 Type: MCSA A senior nursing student is working in an elementary school with the school nurse. The student cares for a child who fell on the school playground and sustained multiple abrasions to the lower extremities. Which action by the nursing student would require immediate intervention by the school nurse? 1. The student nurse puts on nonsterile gloves prior to assessing the child’s injuries. 2. The student nurse disposes of blood-soaked gauze in the office trash bin. 3. The student nurse performs handwashing before touching the child. 4. The student nurse asks the child permission to assess the injuries. Correct Answer: 2 Rationale 1: The use of nonsterile gloves protects the student nurse from direct contact with the child’s blood. Rationale 2: The student nurse should dispose of waste soiled with blood and/or body fluids in a biohazard bin, not the office trash bin.

Rationale 3: Handwashing should be performed before and after client care. Rationale 4: Asking permission to assess the child’s injuries gains the child’s attention and cooperation. Global Rationale: The student nurse should dispose of waste soiled with blood and/or body fluids in a biohazard bin, not the office trash bin. The use of nonsterile gloves protects the student nurse from direct contact with the child’s blood. Handwashing should be performed before and after client care. Asking permission to assess the child’s injuries gains the child’s attention and cooperation. Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Safety and Infection Control Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.5: Apply the principles of Standard Precautions in practice.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 7 Question 1 Type: MCSA The nurse is entering the room to assess a newly admitted client. Which of the following best describes the purpose for a general survey? The general survey: 1. allows for vital signs prior to starting exam. 2. provides an opportunity for the client to relax before the exam. 3. yields information to guide the physical assessment. 4. provides the information necessary for the diagnosis. Correct Answer: 3 Rationale 1: Vital signs are not part of the general survey. The general survey consists of four major observations: physical appearance, mental status, mobility, and behavior. Rationale 2: The purpose of the general survey is to allow the nurse the opportunity to gather clues to guide the rest of the assessment; the purpose is not to give the client an opportunity to relax. Rationale 3: The general survey allows the nurse to observe the client and gain clues to guide the remainder of the assessment. Rationale 4: The general survey does not provide the necessary information to identify client problems or nursing diagnosis, but rather serves as a guide for a more detailed assessment. Global Rationale: The general survey allows the nurse to observe the client and gain clues to guide the remainder of the assessment. Vital signs are not part of the general survey. The purpose of the general survey is to allow the nurse the opportunity to gather clues to guide the rest of the assessment; the purpose is not to give the client an opportunity to relax. The general survey consists of four major observations: physical appearance, mental status, mobility, and behavior. The general survey does not provide the necessary information to identify client problems or nursing diagnosis, but rather serves as a guide for a more detailed assessment. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Safety and Infection Control Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1: Describe the general survey as part of a comprehensive health assessment. Question 2 Type: MCSA

The nurse observes the client walking into the room and climbing up on the exam table. The nurse notes this activity as a way to obtain data related to which of the following? 1. The client’s mobility status 2. Subjective assessments related to ambulation 3. Activity tolerance 4. Strength of upper and lower extremities Correct Answer: 1 Rationale 1: During a general survey, the nurse observes the client performing routine activities, such as walking and sitting. This allows the nurse to begin to gather data about the client’s mobility. These data will then be incorporated into the remainder of exam and history. Rationale 2: Observation is an objective assessment. Rationale 3: Activity tolerance is not a component of the general survey. The general survey consists of physical appearance, mental status, mobility, and behavior. Rationale 4: Watching the client walk and sit gives the nurse information about the strength of a client’s lower extremities, but tells the nurse nothing about the client’s upper extremity strength. Global Rationale: During a general survey, the nurse observes the client performing routine activities, such as walking and sitting. This allows the nurse to begin to gather data about the client’s mobility. These data will then be incorporated into the remainder of exam and history. Observation is an objective assessment. Activity tolerance is not a component of the general survey. The general survey consists of physical appearance, mental status, mobility, and behavior. Watching the client walk and sit gives the nurse information about the strength of a client’s lower extremities, but tells the nurse nothing about the client’s upper extremity strength. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1: Describe the general survey as part of the comprehensive health assessment. Question 3 Type: MCMA The nurse is assessing an adult client. Which of the following observations should the nurse include when documenting the general survey of this client? Standard Text: Select all that apply. 1. Blood pressure 112/68, pulse 68, 98.6 (F), respiratory rate 16.

2. Thin, well-nourished male client, appears younger than stated age. 3. Client moves about exam room without difficulty. 4. Abdomen flat, nondistended, bowel sounds present, nontender on palpation. 5. Responds appropriately to questions. Correct Answer: 2,3,5 Rationale 1: Blood pressure 112/68, pulse 68, 98.6 (F), respiratory rate 16. The vital signs are objective information, but not part of the actual general survey. Rationale 2: Thin, well-nourished male client, appears younger than stated age. The general survey is composed of 4 major categories of observation: physical appearance, mental status, mobility, and behavior of the client. The documentation thin, well-nourished male client, appears younger than stated age reflects the client’s physical appearance, one of the components of the general survey. Rationale 3: Client moves about exam room without difficulty. The documentation client moves about exam room without difficulty describes the client’s overall mobility, another component of the general survey. Rationale 4: Abdomen flat, nondistended, bowel sounds present, nontender on palpation. The documentation abdomen flat, nondistended, bowel sounds present, nontender on palpation is specific to the abdominal assessment and not part of the general survey. Rationale 5: Responds appropriately to questions. The documentation responds appropriately to questions comments on the nurse’s observations regarding the client’s behavior and mental status, 2 other components of the general survey. Global Rationale: The general survey is composed of 4 major categories of observation: physical appearance, mental status, mobility, and behavior of the client. The documentation thin, well-nourished male client, appears younger than stated age reflects the client’s physical appearance, one of the components of the general survey. The documentation client moves about exam room without difficulty describes the client’s overall mobility, another component of the general survey. The documentation responds appropriately to questions comments on the nurse’s observations regarding the client’s behavior and mental status, 2 other components of the general survey. The vital signs are objective information, but not part of the actual general survey. The documentation abdomen flat, nondistended, bowel sounds present, nontender on palpation is specific to the abdominal assessment and not part of the general survey. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.2: Identify components of the general survey. Question 4 Type: MCSA

The nurse is preparing to assess a client’s mental status within the general survey. Which of the following should the nurse use to assess this status? 1. Note the number of times the client looks to significant other while answering interview questions. 2. Ask the client to describe elements of his health history. 3. Study the client’s clothing selections. 4. Notice the client’s ability to make eye contact during the examination. Correct Answer: 2 Rationale 1: Observing the client walking into the examination room would help assess mobility. Rationale 2: The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and client behavior. Asking the client to describe elements of his health history would help assess mental status. Rationale 3: Studying the client’s clothing selections would help assess physical appearance. Rationale 4: Noticing the client’s ability to make eye contact would help assess client behavior. Global Rationale: The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and client behavior. Asking the client to describe elements of his health history would help assess mental status. Observing the client walking into the examination room would help assess mobility. Studying the client’s clothing selections would help assess physical appearance. Noticing the client’s ability to make eye contact would help assess client behavior. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.2: Identify parts of the general survey. Question 5 Type: MCSA During an interview with an older adult client, the nurse notes the client is confused as to day and time. The nurse would document this finding as an indicator of which of the following? 1. Affect and mood 2. Orientation 3. Willingness to cooperate 4. Level of anxiety

Correct Answer: 2 Rationale 1: The client’s affect and mood are revealed through speech, body language and facial expression. Rationale 2: Client’s ability to state name, location, and the date and time of day assesses orientation to person, place, and time. Rationale 3: The client was not uncooperative, but rather confused to day and time. Rationale 4: Like affect and mood, the client’s level of anxiety is revealed through speech, body language and facial expression. Global Rationale: Client’s ability to state name, location, and the date and time of day assesses orientation to person, place, and time. The client’s affect and mood are revealed through speech, body language and facial expression. The client was not uncooperative, but rather confused to day and time. Like affect and mood, the client’s level of anxiety is revealed through speech, body language and facial expression. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.2: Identify components of the general survey. Question 6 Type: MCSA The nurse is obtaining the initial vital signs on a client in the emergency room with seizure activity of unknown etiology. The nurse should choose which of the following methods to obtain the most accurate reading of the client’s temperature? 1. Axillary 2. Oral 3. Rectal 4. Tympanic Correct Answer: 3 Rationale 1: Although axillary is the safest, it is also the least accurate. Rationale 2: Measuring the temperature orally requires the client’s cooperation, which is not possible during seizure activity. Rationale 3: A rectal temperature should be taken if the client is comatose, confused, having seizures, or unable to close the mouth.

Rationale 4: Measuring the temperature tympanically requires the client’s cooperation, which is not possible during seizure activity. Global Rationale: A rectal temperature should be taken if the client is comatose, confused, having seizures, or unable to close the mouth. Although axillary is the safest, it is also the least accurate. Both oral and tympanic require the client’s cooperation in order to maintain safety, which is not possible during seizure activity. Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Safety and Infection Control Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Measure vital signs. Question 7 Type: HOTSPOT The nurse is assessing a client’s left femoral pulse. Identify the area on the diagram below where the nurse would locate this pulse.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The nurse would palpate the left femoral pulse over the left femoral artery of the client. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Measure vital signs. Question 8 Type: MCSA The nurse is caring for a pediatric client and needs to obtain vital signs. Which of the following route and sequence will the nurse use to obtain vital signs on a healthy newborn? 1. Rectal temperature, respirations, pulse rate 2. Respirations, pulse rate, blood pressure, rectal temperature 3. Respirations, apical pulse rate, axillary temperature

4. Oral temperature, respirations, pulse rate, blood pressure Correct Answer: 3 Rationale 1: The temperature should be taken last, as it may cause the infant to cry, altering the rate of respirations and pulse. Rationale 2: A blood pressure is not a routine vital sign obtained on a healthy infant. If a blood pressure is done, a Doppler stethoscope is used in infants and children under the age of 2. Rationale 3: Respirations should be assessed first in the assessment of a newborn, followed by the apical pulse, and finally the temperature. The rectal temperature is the most accurate; however an axillary temperature is appropriate since it can lead to rectal perforation. Rationale 4: Oral temperatures are not used for temperature measurement in children under the age of 5. Global Rationale: Respirations should be assessed first in the assessment of a newborn, followed by the apical pulse, and finally the infant’s temperature. While the rectal temperature is the most accurate, there is risk of rectal perforation. This question addresses a “healthy” newborn; therefore an axillary temperature is appropriate. The temperature (any route) should be assessed last, as it may cause the infant to cry, altering the rate of respirations and pulse. A blood pressure is not a routine vital sign obtained on a healthy infant. If a blood pressure is done, a Doppler stethoscope is used in infants and children under the age of 2. Oral temperatures are not used for temperature measurement in children under the age of 5. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Measure vital signs. Question 9 Type: MCSA A young adult client presents to the clinic complaining of a sore throat, swollen glands, and fever following oral surgery for extraction of impacted wisdom teeth. In order to complete the initial assessment of this client, the nurse needs to obtain the client’s temperature. Which method should the nurse choose for this assessment? 1. Oral 2. Tympanic 3. Rectal 4. Axillary Correct Answer: 2

Rationale 1: The nurse would not want to use the oral route for this client since the client has recently had oral surgery. Rationale 2: The nurse should take the client’s temperature using a tympanic thermometer. Infection may be a concern in this client; therefore, an accurate temperature is necessary. Using the ear for temperature assessment is quick, noninvasive, and reliable. Rationale 3: A rectal temperature is invasive and unnecessary in the assessment of this client’s temperature. Rationale 4: The axillary route is sometimes used in the temperature assessment of infants and children. It is considered the least accurate method of measurement. Global Rationale: The nurse should take the client’s temperature using a tympanic thermometer. Infection may be a concern in this client; therefore, an accurate temperature is necessary. Using the ear for temperature assessment is quick, noninvasive, and reliable. The nurse would not want to use the oral route for this client since the client has recently had oral surgery. A rectal temperature is invasive and unnecessary in the assessment of this client’s temperature. The axillary route is sometimes used in the temperature assessment of infants and children. It is considered the least accurate method of measurement. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Measure vital signs. Question 10 Type: MCSA While assessing an adult client’s pulse, the nurse notes an irregular rate. The nurse should assess the pulse by counting the beats for: 1. 2 minutes. 2. 1 minute. 3. 30 seconds and multiply by 2. 4. 15 seconds and multiply by 4. Correct Answer: 2 Rationale 1: It is not necessary for the nurse to count the pulse for 2 minutes, as heart rate is expressed in beats per minute. Rationale 2: With any irregular pulse, the rate needs to be counted for 1 full minute. Rationale 3: If the pulse is regular, the nurse may count the beats for 30 seconds and multiply by 2.

Rationale 4: Counting for 15 seconds and multiplying by 4 may not yield an accurate result, and therefore should not be used in assessing the rate. Global Rationale: With any irregular pulse, the rate needs to be counted for 1 full minute. It is not necessary for the nurse to count the pulse for 2 minutes, as heart rate is expressed in beats per minute. If the pulse is regular, the nurse may count the beats for 30 seconds and multiply by 2. Counting for 15 seconds and multiplying by 4 may not yield an accurate result, and therefore should not be used in assessing the rate. Cognitive Level: Understanding Client Need: Safe Effective Care Environment Client Need Sub: Safety and Infection Control Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Measure vital signs. Question 11 Type: MCSA The nurse educator is preparing an inservice on pain management for the staff. One of the staff nurses asks, “What is the most important part of a pain assessment?” How should the nurse educator respond to this question? 1. “Pain is only partially subjective and primarily a physiologic experience, so vital signs are the most important assessment.” 2. “A client’s response to pain is always based on the underlying cause, so the client’s admitting diagnosis is important.” 3. “Vital signs are not reliable indicators of acute pain, because only some clients are able to elicit a change in blood pressure or pulse rate.” 4. “The response to pain is unique and based on numerous factors, which need to be assessed.” Correct Answer: 4 Rationale 1: Vital signs are only a portion of the pain assessment. The nurse must consider many factors since pain is an individual experience and no two people experience pain in the same way. A patient’s level of pain cannot be determined by his physiologic response only. Rationale 2: Pain is unique to each person and may be experienced differently by clients with the same diagnosis. Rationale 3: Vital signs can be indicators of pain. In the early stages of acute pain, the sympathetic nervous system is stimulated, causing increases in blood pressure, pulse, and respiratory rates. Rationale 4: Pain is a subjective experience, and the response is unique to each individual. The factors that impact the response are numerous and include age, sex, culture, and developmental level, as well as previous experience with pain and health status. Global Rationale: Pain is a subjective experience, and the response is unique to each individual. The factors that impact the response are numerous and include age, sex, culture, and developmental level, as well as previous

experience with pain and health status. Vital signs are only a portion of the pain assessment. The nurse must consider many factors since pain is an individual experience and no two people experience pain in the same way. A patient’s level of pain cannot be determined by his physiologic response only. Pain is unique to each person and may be experienced differently by clients with the same diagnosis. Vital signs can be indicators of pain. In the early stages of acute pain, the sympathetic nervous system is stimulated, causing increases in blood pressure, pulse, and respiratory rates. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.3: Measure vital signs. Question 12 Type: FIB During the assessment of an adult client’s blood pressure, the nurse notes the following on the sphygmomanometer: first faint tapping sounds at 136, swishing sounds at 120, clear tapping sounds at 108, muffled sounds at 98, and silence at 76. This nurse would document this client’s blood pressure as . Standard Text: Correct Answer: 136/76 Rationale : The sounds above are the 5 phases of Korotkoff’s sounds. The first sound heard (Phase 1) is recorded as the systolic blood pressure. This is when the blood pressure cuff has been released just enough to allow the first spurts of blood to pass through the artery. Phase 2 is marked by the period in which the sounds change from tapping to swishing; blood flows turbulently through the artery. Phase 3 is when blood flows through the artery during systole but collapses during diastole; the sounds are crisp and tapping. During Phase 4, the sounds become muffled and have a soft blowing quality. The pressure in the cuff does not completely collapse the artery in any part of the cardiac cycle. The diastolic blood pressure is marked by the beginning of silence (Phase 5). This is when the cuff no longer collapses the artery, and blood is free flowing through the artery. Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Measure vital signs. Question 13 Type: MCSA The nurse is assessing a 15-month-old baby. The nurse should assess this baby’s pulse rate by using the:

1. Radial artery. 2. Brachial artery. 3. Apical site. 4. Carotid artery. Correct Answer: 3 Rationale 1: In older children and adults, the radial artery is used to assess the pulse. Rationale 2: In preschool children, the brachial artery is used to assess the pulse. Rationale 3: The apical site is the site of choice to assess the pulse rate of a child who is under 2 years of age. Rationale 4: The carotid pulse is assessed in adult clients as part of the cardiovascular assessment. Global Rationale: The apical site is the site of choice to assess the pulse rate of a child who is under 2 years of age. In preschool children, the brachial artery is used to assess the pulse. In older children and adults, the radial artery is used to assess the pulse. The carotid pulse is assessed in adult clients as part of the cardiovascular assessment. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Measure vital signs. Question 14 Type: MCMA The nursing instructor is observing the student nurse take a blood pressure on an older adult client. The nursing instructor intervenes when the student nurse is observed doing which of the following? Standard Text: Select all that apply. 1. The student nurse ushers the client into the exam room and immediately assesses the client’s blood pressure. 2. The student nurse places the blood pressure cuff on the client’s arm over a lightweight, long-sleeved sweater. 3. The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure. 4. The student nurse has the client sit in a chair and supports the client’s arm on a table at the level of the heart. 5. The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery.

Correct Answer: 1,2,3 Rationale 1: The student nurse ushers the client into the exam room and immediately assesses the client’s blood pressure. The client should sit quietly for at least 5 minutes before the blood pressure is taken. Immediately assessing the blood pressure after a client walks from the waiting room to exam room may not yield an accurate reading. Rationale 2: The student nurse places the blood pressure cuff on the client’s arm over a lightweight, longsleeved sweater. The client’s blood pressure should be assessed on a bare arm. If the client is wearing a long sleeved garment and it can be pushed up without constricting the arm, this is acceptable; otherwise the arm should be removed from the sleeve. Rationale 3: The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure. Once the cuff is inflated and the nurse identifies the palpatory systolic blood pressure, the nurse should wait at least 15–30 seconds before inflating the cuff again. Rationale 4: The student nurse has the client sit in a chair and supports the client’s arm on a table at the level of the heart. In order to obtain an accurate blood pressure, the client should be seated with the arm slightly flexed, supported at the level of the heart with palm facing up. Rationale 5: The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery. Clients who have suffered trauma to the upper extremities, have shunts in the upper extremities, or have had mastectomies should not have their blood pressures assessed on the affected sides. The nurse can place the blood pressure cuff on the thigh and assess the blood pressure using the popliteal artery. Global Rationale: The client should sit quietly for at least 5 minutes before the blood pressure is taken. Immediately assessing the blood pressure after a client walks from the waiting room to exam room may not yield an accurate reading. The client’s blood pressure should be assessed on a bare arm. If the client is wearing a longsleeved garment and it can be pushed up without constricting the arm, this is acceptable; otherwise the arm should be removed from the sleeve. Once the cuff is inflated and the nurse identifies the palpatory systolic blood pressure, the nurse should wait at least 15–30 seconds before inflating the cuff again. In order to obtain an accurate blood pressure, the client should be seated with the arm slightly flexed, supported at the level of the heart with palm facing up. Clients who have suffered trauma to the upper extremities, have shunts in the upper extremities, or have had mastectomies should not have their blood pressures assessed on the affected sides. The nurse can place the blood pressure cuff on the thigh and assess the blood pressure using the popliteal artery. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Measure vital signs. Question 15 Type: MCSA

The nurse is assessing a toddler when the child’s mother tells the nurse that the child has had a fever for the past two days. When the nurse asks the mother what the temperature has been, the mother replies that she hasn’t actually taken it but the child’s skin has felt very warm. Which of the following would be the most appropriate response for the nurse? 1. “When our skin feels warm, it means our blood vessels are constricted.” 2. “The only reliable indicator of body temperature is by feeling the forehead.” 3. “Our skin temperature changes when our surroundings change temperature.” 4. “The temperature of the skin is not related to what is happening inside our bodies.” Correct Answer: 3 Rationale 1: Fever causes vasodilation, not vasoconstriction. Rationale 2: When fever is present, the skin all over the body may feel warm, not just the forehead, thus the only reliable indicator of body temperature is measuring the core temperature with a thermometer. Rationale 3: The surface temperature of the body is constantly changing in response to environmental influences and as a result is not a reliable indicator of actual health status. To obtain accurate temperature, the core temperature, or the temperature of the deep tissues of the body, needs to be assessed. Rationale 4: The temperature of the skin is related to what is happening inside the body. Fever is a sign of the disruption of homeostasis in the body. This may be due to a bacterial or viral infection. Fever causes vasodilation, which can make the skin feel warm to the touch. Global Rationale: The surface temperature of the body is constantly changing in response to environmental influences and as a result is not a reliable indicator of actual health status. To obtain accurate temperature, the core temperature, or the temperature of the deep tissues of the body, needs to be assessed. Fever causes vasodilation, not vasoconstriction. When fever is present, the skin all over the body may feel warm, not just the forehead, thus the only reliable indicator of body temperature is measuring the core temperature with a thermometer. The temperature of the skin is related to what is happening inside the body. Fever is a sign of the disruption of homeostasis in the body. This may be due to a bacterial or viral infection. Fever causes vasodilation, which can make the skin feel warm to the touch. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.4: Discuss factors that affect vital signs. Question 16 Type: MCMA The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure reading of 172/98. The nurse understands that the following factors may be applicable in this situation.

Standard Text: Select all that apply. 1. Arteriosclerosis decreases the ventricular force necessary for ejection of blood. 2. Arteriosclerosis increases blood vessel elasticity. 3. Arteriosclerosis decreases blood vessel compliance. 4. Age decreases blood vessel elasticity. 5. Arteriosclerosis plays no role in the blood pressure of this client. Correct Answer: 3,4 Rationale 1: Arteriosclerosis decreases the ventricular force necessary for ejection of blood. Arteriosclerosis requires greater ventricular force and leads to increased blood pressure. Rationale 2: Arteriosclerosis increases blood vessel elasticity. Arteriosclerosis decreases the elasticity of the arteries. Rationale 3: Arteriosclerosis decreases blood vessel compliance. Arteriosclerosis results in hardened and rigid arteries, which are less compliant. Rationale 4: Age decreases blood vessel elasticity. Elasticity of blood vessels decreases with age and also leads to increased blood pressure. Rationale 5: Arteriosclerosis plays no role in the blood pressure of this client. Arteriosclerosis plays no role in the blood pressure of this client. Global Rationale: Arteriosclerosis results in hardened and rigid arteries, which are less compliant. Elasticity of blood vessels decreases with age and also leads to increased blood pressure. Arteriosclerosis requires greater ventricular force and leads to increased blood pressure. Arteriosclerosis decreases the elasticity of the arteries. Arteriosclerosis has a direct effect on blood pressure; decreased elasticity and compliance is directly related to the increase in blood pressure. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.4: Discuss factors that affect vital signs. Question 17 Type: MCSA The nurse needs to take a blood pressure on a very thin client, and the only cuff available is a standard size. The nurse would anticipate which of the following readings? 1. An accurate reading

2. A falsely elevated reading 3. The reading will depend on the overall health of the client 4. A false low reading Correct Answer: 4 Rationale 1: In a very thin client, a small (or even pediatric) blood pressure cuff should be used to obtain an accurate reading. Using a standard cuff on this client will yield a falsely low result. Rationale 2: When the bladder of the cuff is too narrow, the blood pressure reading will be falsely elevated. Rationale 3: While the reading will depend on the overall health of the client, it is important to obtain an accurate reading by using the proper equipment. Rationale 4: In this situation, the bladder of the cuff is too wide, resulting in the blood pressure reading being falsely low. To obtain accurate blood pressure readings, it is imperative that the nurse select the proper cuff. The bladder of the blood pressure cuff must be an appropriate fit in both length and width for the client’s arm. The length of the bladder should equal 80% of the circumference of the limb. The width of the bladder should equal 40% of the circumference of the limb. Global Rationale: In this situation, the bladder of the cuff is too wide, resulting in the blood pressure reading being falsely low. To obtain accurate blood pressure readings, it is imperative that the nurse select the proper cuff. The bladder of the blood pressure cuff must be an appropriate fit in both length and width for the client’s arm. The length of the bladder should equal 80% of the circumference of the limb. The width of the bladder should equal 40% of the circumference of the limb. In a very thin client, a small (or even pediatric) blood pressure cuff should be used to obtain an accurate reading. Using a standard cuff on this client will yield a falsely low result. When the bladder of the cuff is too narrow, the blood pressure reading will be falsely elevated. While the reading will depend on the overall health of the client, it is important to obtain an accurate reading by using the proper equipment. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.4: Discuss the factors that affect vital signs. Question 18 Type: MCSA The nurse is caring for a client diagnosed with breast cancer, who underwent a left-sided mastectomy two days prior. The nurse has delegated vital signs on this client to the patient care assistant (PCA). What specific instructions should the nurse provide to the (PCA) in delegating this task? 1. Take the blood pressure on the right arm. 2. No special instructions are needed.

3. Take the blood pressure on the left arm. 4. Take the blood pressure on both arms for a baseline. Correct Answer: 1 Rationale 1: The blood pressure should be taken in the arm opposite the surgical site. Blood pressures should not be taken on the same side as a mastectomy. It should also not be taken on an arm with a shunt, trauma, or disease. If this is not possible, then a thigh pressure should be obtained. Rationale 2: The nurse should be sure to provide the PCA with instructions to use the arm opposite the surgical site for blood pressure readings. Rationale 3: The left arm should not be used for blood pressure readings, intravenous fluids, or other invasive procedures. Rationale 4: It is not possible to take the blood pressure using both arms, since the left arm should never be used again for blood pressure readings. If bilateral readings become necessary, the thighs should be used so that a comparison can be made. Global Rationale: The blood pressure should be taken in the arm opposite the surgical site. Blood pressures should not be taken on the same side as a mastectomy. It should also not be taken on an arm with a shunt, trauma, or disease. If this is not possible, then a thigh pressure should be obtained. The nurse should be sure to provide the PCA with instructions to use the arm opposite the surgical site for blood pressure readings. The left arm should not be used for blood pressure readings, intravenous fluids, or other invasive procedures. It is not possible to take the blood pressure using both arms, since the left arm should never be used again for blood pressure readings. If bilateral readings become necessary, the thighs should be used so that a comparison can be made. Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.4: Discuss factors that affect vital signs. Question 19 Type: MCSA A young adult client notes height as “5 feet 11 inches” and weight as “200 lbs.” Upon assessment, the client is found to be 5 feet 9 inches tall with a weight of 225 lbs. The nurse identifies the most likely reason for this discrepancy between the client’s self-reported height and weight and the objective information indicates: 1. The client does not have a scale at home. 2. The client may have a image of self inconsistent with actual findings. 3. The client did not want to tell the truth. 4. The client is trying to hide a chronic illness.

Correct Answer: 2 Rationale 1: The best reason for the inconsistency is the client has a different image of himself than what is objectively measurable. Rationale 2: The nurse has no way of knowing if the client has a scale at home and does not account for the discrepancy in height. Rationale 3: The inconsistency between reported height and weight and actual height and weight does not mean the client is being untruthful; it is what the client believes to be true. Rationale 4: The inconsistency between reported height and actual height and weight does not indicate that the client is trying to hide a chronic illness. Global Rationale: The best reason for the inconsistency is the client has a different image of himself than what is objectively measurable. The nurse has no way of knowing if the client has a scale at home and does not account for the discrepancy in height. The inconsistency between reported height and weight and actual height and weight does not mean the client is being untruthful; it is what the client believes to be true. The inconsistency between reported height and actual height and weight does not indicate that the client is trying to hide a chronic illness. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7.4: Discuss factors that affect vital signs. Question 20 Type: MCSA During the evening assessment of a febrile client admitted to the nursing unit with abdominal pain, the nurse assesses a lower than normal blood pressure and a rapid pulse. These findings suggest to the nurse that the client may be experiencing: 1. anxiety. 2. an abdominal infection. 3. a medication reaction. 4. a diurnal variation Correct Answer: 2 Rationale 1: The physiologic response to anxiety is increased heart rate and increased blood pressure. Rationale 2: The lowered blood pressure and increased heart rate in a febrile client with abdominal pain is suggestive of infection. Fever causes vasodilation, which in turn causes an increase in heart rate.

Rationale 3: There is no information to suggest that the client is experiencing a reaction to medication. Rationale 4: Diurnal variation of blood pressure is exhibited by lower morning blood pressure that increases throughout the day. Global Rationale: The lowered blood pressure and increased heart rate in a febrile client with abdominal pain is suggestive of infection. Fever causes vasodilation, which in turn causes an increase in heart rate. The physiologic response to anxiety is increased heart rate and increased blood pressure. There is no information to suggest that the client is experiencing a reaction to medication. Diurnal variation of blood pressure is exhibited by lower morning blood pressure that increases throughout the day. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7.4: Discuss the factors that affect vital signs. Question 21 Type: MCSA An older adult client says to the nurse, “I’m gaining weight around my middle and my legs look like chicken legs.” An appropriate response by the nurse to this client is: 1. “Older people often put on weight around the middle, but lose muscle in the legs, making the legs appear thinner. This is normal.” 2. “Have you been doing any exercises to slim down your middle?” 3. “This is very unusual. I will let the healthcare provider know.” 4. “Let’s talk about your diet to see why you’re gaining weight around your middle.” Correct Answer: 1 Rationale 1: Older adults experience a decrease in overall muscle mass and they lose subcutaneous fat in the face forearms and legs; however, there is an increase in fat deposits in the abdomen and hips. This is a normal occurrence in the older adult client. Rationale 2: While exercise is important for overall health and the client should be encouraged to participate in 30 minutes of exercise on most days, this is a normal occurrence in the older adult and this should be explained to the client. Rationale 3: This is not an unusual finding in an older adult client. It is not necessary to alert the healthcare provider. Rationale 4: Excessive calorie intake would lead to weight gain all over the body, not just the middle.

Global Rationale: Older adults experience a decrease in overall muscle mass and they lose subcutaneous fat in the face forearms and legs; however, there is an increase in fat deposits in the abdomen and hips. This is a normal occurrence in the older adult client. While exercise is important for overall health and the client should be encouraged to participate in 30 minutes of exercise on most days, this is a normal occurrence in the older adult and this should be explained to the client. This is not an unusual finding in an older adult client. It is not necessary to alert the healthcare provider. Excessive calorie intake would lead to weight gain all over the body, not just the middle. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.4: Discuss factors that affect vital signs. Question 22 Type: MCSA The night nurse is reviewing the vital signs of a client in an extended care facility. The nurse notes the client’s oral temperature at 6 a.m. was 98.0°F, but that evening, the client’s oral temperature was 99.2°F. The nurse suspects that this variation in temperature is indicative of: 1. The client’s temperature has been improperly assessed either in the morning or evening; the nurse can’t be sure which. 2. The client is developing an infection. 3. The client is experiencing stress. 4. The client’s temperature is demonstrating diurnal variations. Correct Answer: 4 Rationale 1: The difference in body temperature is evidence of diurnal variation. Core body temperature is lowest during the early morning and becomes higher during the course of the day. Rationale 2: There is no evidence to suggest the temperatures were incorrectly assessed and the same routes were used for both assessments. Rationale 3: There is no evidence to suggest that the client is developing an infection other than the higher evening body temperature. Rationale 4: There is nothing to suggest that this client is under a great deal of stress which may elevate body temperature. Global Rationale: The difference in body temperature is evidence of diurnal variation. Core body temperature is lowest during the early morning and becomes higher during the course of the day. There is no evidence to suggest the temperatures were incorrectly assessed and the same routes were used for both assessments. There is no

evidence to suggest that the client is developing an infection other than the higher evening body temperature. There is nothing to suggest that this client is under a great deal of stress, which might elevate body temperature. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7.4: Discuss factors that affect vital signs. Question 23 Type: MCMA A nurse has been asked to present a program on blood pressure for a group of adults at a community center. Which of the following true statements should the nurse incorporate into the presentation? Standard Text: Select all that apply. 1. Females tend to have higher blood pressure readings than males of the same age. 2. Middle-aged African American males tend to have higher blood pressures than American males of European descent. 3. Stress can result in an increase in blood pressure. 4. Blood pressure readings tend to be lowest in the evening. 5. During physical activity, blood pressure decreases. Correct Answer: 2,3 Rationale 1: Females tend to have higher blood pressure readings than males of the same age. After puberty, females tend to have lower blood pressure readings than males of the same age. Rationale 2: Middle-aged African American males tend to have higher blood pressures than American males of European descent. African American males over the age of 35 tend to have higher blood pressure readings than American males of European descent. Rationale 3: Stress can result in an increase in blood pressure. Stress increases cardiac output and arterial vasoconstriction, resulting in increased blood pressure. Rationale 4: Blood pressure readings tend to be lowest in the evening. Blood pressure is sensitive to diurnal variations; blood pressure is lower in the morning and peaks in the late afternoon. Rationale 5: During physical activity, blood pressure decreases. During physical activity, blood pressure increases due to the increase in cardiac output. Global Rationale: African American males over the age of 35 tend to have higher blood pressure readings than American males of European descent. Stress increases cardiac output and arterial vasoconstriction, resulting in

increased blood pressure. After puberty, females tend to have lower blood pressure readings than males of the same age. Blood pressure is sensitive to diurnal variations; blood pressure is lowest in the morning and peaks in the late afternoon. During physical activity, blood pressure increases due to the increase in cardiac output. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.4: Discuss factors that affect vital signs. Question 24 Type: MCMA A client presents to the primary care clinic and is disheveled in appearance, with stained, dirty clothing, body odor, and uncombed hair. Based on this observation, which of the following should the nurse assess during the history and physical exam? Standard Text: Select all that apply. 1. Occupation 2. Depression 3. Smoking history 4. Self-concept 5. Immunization status Correct Answer: 1,2,4 Rationale 1: Occupation. The way a client dresses and maintains physical hygiene may provide clues to the client’s occupation (perhaps the client has a physical job and has just come from work). Rationale 2: Depression. The way a client dresses and maintains physical hygiene may provide clues to the state of the client’s mental health. Rationale 3: Smoking history. The client’s disheveled appearance does not directly clue the nurse to explore the client’s smoking history. Clues that would lead the nurse to fully explore the client’s smoking history would include the smell of smoke on the client, the discoloration of the fingers from tobacco, hoarseness of the voice, and/or a cough. Rationale 4: Self-concept. The way a client dresses and maintains physical hygiene may provide clues to the client’s sense of self-esteem and body image. Rationale 5: Immunization status. The observations made by the nurse do not clue the nurse to assess the client’s immunization status.

Global Rationale: The way a client dresses and maintains physical hygiene may provide clues to a variety of things, such as what the client does for a living (perhaps the client has a physical job and has just come from work), the client’s sense of self-esteem and body image, as well as be an indicator of mental illness, anxiety, or depression. The client’s disheveled appearance does not directly clue the nurse to explore the client’s smoking history. Clues that would lead the nurse to fully explore the client’s smoking history would include the smell of smoke on the client, the discoloration of the fingers from tobacco, hoarseness of the voice, and/or a cough. The observations made by the nurse do not clue the nurse to assess the client’s immunization status. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 25 Type: MCSA The nurse is doing a general survey on an infant for a well-child check. During the survey, the baby has a liquid stool. The mother becomes very angry and asks the nurse to change the diaper because she just can’t “deal with the odor.” This response is important to the nurse because: 1. the child may have an illness causing diarrhea. 2. it may be a reflection of the mother-child relationship. 3. the mother may be feeding the child a poor diet. 4. the child may have an illness that is increasing the odor of stool. Correct Answer: 2 Rationale 1: The loose stool may be a sign of illness; however, there is not enough information to determine if the child is ill, and the mother’s response is inappropriate. Rationale 2: Observation of the interaction between the child and mother can provide information suggestive of child abuse. The mother’s demonstration of disgust with any aspect of child’s behavior or such things as odor or stool can be clues that there may be a problem with the relationship and should be evaluated further. Rationale 3: The loose stool may be the result of the child’s diet; however, the mother’s response is inappropriate. Rationale 4: The loose stool may be a sign of illness; however, there is not enough information to determine if the child is ill, and the mother’s response is inappropriate. Global Rationale: Observation of the interaction between the child and mother can provide information suggestive of child abuse. The mother’s demonstration of disgust with any aspect of child’s behavior or such things as odor or stool can be clues that there may be a problem with the relationship and should be evaluated further. The loose stool may be a sign of illness; however, there is not enough information to determine if the

child is ill, and the mother’s response is inappropriate. The loose stool may be the result of the child’s diet; however, the mother’s response is inappropriate. The loose stool may be a sign of illness; however, there is not enough information to determine if the child is ill, and the mother’s response is inappropriate. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 26 Type: MCSA The nursing assistant brings the nurse the following vital signs for an older adult client: Temperature 97.4ºF (oral), BP 165/70, Pulse Rate 84/min, and Respirations 28. After reviewing the vital signs, the nurse should do which of the following? 1. Continue to monitor the client. 2. Tell the nursing assistant to recheck the temperature. 3. Obtain an order for an antihypertensive. 4. Obtain an order for oxygen therapy. Correct Answer: 1 Rationale 1: Normal variations in vital signs occur with aging. Body temperature may be decreased due to a decrease in the thermoregulatory control and loss of subcutaneous fat. The pulse rate remains within the normal range of 60 to 100 BPM. A decrease in vital capacity and inspiratory reserve volume may result in an increased respiratory rate. Because systemic arteries lose elasticity with aging, the heart has greater resistance to pump against, which can result in an increased systolic blood pressure. No interventions are needed at this time. Rationale 2: The temperature is within a normal range for this client; there is no need to recheck the temperature. Rationale 3: While the systolic blood pressure reading is higher than the upper limit of normal, one elevated reading of 165 systolic is not an indication for antihypertensive therapy. The nurse should continue to monitor this client’s blood pressure and alert the healthcare provider if the systolic blood pressure remains elevated. Rationale 4: The client’s vital signs are within a normal range; there is no indication for oxygen therapy. Global Rationale: Normal variations in vital signs occur with aging. Body temperature may be decreased due to a decrease in the thermoregulatory control and loss of subcutaneous fat. The pulse rate remains within the normal range of 60 to 100 BPM. A decrease in vital capacity and inspiratory reserve volume may result in an increased respiratory rate. Because systemic arteries lose elasticity with aging, the heart has greater resistance to pump against, which can result in an increased systolic blood pressure. No interventions are needed at this time. The temperature is within a normal range for this client; there is no need to recheck the temperature. While the systolic blood pressure reading is higher than the upper limit of normal, one elevated reading of 165 systolic is not an

indication for antihypertensive therapy. The nurse should continue to monitor this client’s blood pressure and alert the healthcare provider if the systolic blood pressure remains elevated. The client’s vital signs are within a normal range; there is no indication for oxygen therapy. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 27 Type: MCSA The nurse is obtaining the height and weight of an older adult client. The client asks why the height is 1 inch less than last year. What is the best response by the nurse? 1. “Your bones are weaker and are shrinking.” 2. “I am sure you are mistaken and just don’t remember from last year.” 3. “Your height decreases with age due to musculoskeletal changes.” 4. “Stand up straighter this time and we will measure again.” Correct Answer: 3 Rationale 1: During the older adult years the bones may lose density, but they do not shrink. Rationale 2: To confront the client and say “I am sure you are mistaken and just don’t remember from last year” is an inappropriate response and does not answer the client’s question. Rationale 3: Height of older adults may decrease as a result of thinning of the intervertebral discs. There can also be a flexion of the hips and knees, which affects the ability to stand erect. Rationale 4: There can also be a flexion of the hips and knees, which affects the ability to stand erect. Global Rationale: Height of older adults may decrease as a result of thinning of the intervertebral discs. There can also be a flexion of the hips and knees, which affects the ability to stand erect. During the older adult years the bones may lose density, but they do not shrink. To confront the client and say “I am sure you are mistaken and just don’t remember from last year” is an inappropriate response and does not answer the client’s question. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 28

Type: MCSA The nurse is caring for a client with pneumonia and has obtained the following vital signs: Temperature 101.2ºF (oral), BP 100/70, Pulse Rate 110/min, and Respirations 22. The client’s oxygen saturation level is 96%. The nurse should clarify which of the following orders? 1. Administer acetaminophen (Tylenol) 650 mg every 4 hours prn fever. 2. Administer intravenous (IV) fluids: 0.9% Normal Saline Solution at 125 ml/hour. 3. Start oxygen therapy at 3L/minute via nasal cannula. 4. Send for chest x-ray. Correct Answer: 3 Rationale 1: The order for acetaminophen (Tylenol) is appropriate and is to be given as needed for fever. Rationale 2: The order for IV fluids is appropriate as fluids help to thin secretions and make up for increased insensible loss due to fever and increased respiratory rate. Rationale 3: The nurse should clarify the oxygen therapy order. Although the client’s respiratory rate is slightly increased, this is an expected finding in a client with fever and a diagnosis of pneumonia. The client’s oxygen saturation level of 96% is within normal limits; therefore the client does not need oxygen therapy. Rationale 4: A chest film would be indicated to determine the extent of pulmonary involvement. Global Rationale: The nurse should clarify the oxygen therapy order. Although the client’s respiratory rate is slightly increased, this is an expected finding in a client with fever and a diagnosis of pneumonia. The client’s oxygen saturation level of 96% is within normal limits; therefore the client does not need oxygen therapy. The order for acetaminophen (Tylenol) is appropriate and is to be given as needed for fever. The order for IV fluids is appropriate as fluids help to thin secretions and make up for increased insensible loss due to fever and increased respiratory rate. A chest film would be indicated to determine the extent of pulmonary involvement. Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Safety and Infection Control Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 29 Type: MCSA The nursing staff is admitting a client diagnosed with diabetic ketoacidosis (DKA). The LPN asks the RN if the pulse oximeter needs to be placed on the client. What is the nurse’s best response to the LPN? 1. “Please place the pulse oximeter on the client.”

2. “I will let you know after I complete my assessment.” 3. “Thanks, but that is something I have to do for the client.” 4. “We don’t have an order to do that.” Correct Answer: 2 Rationale 1: Clients in DKA may not require a pulse oximeter as it does not provide information about acid-base balance or blood glucose levels. It reflects only the percentage of oxygen saturation of hemoglobin. Rationale 2: The nurse should complete the assessment to determine any respiratory abnormalities before using the pulse oximeter. Rationale 3: If the RN determines the pulse oximeter is needed, the RN could delegate the task to the LPN. Rationale 4: This would not require a healthcare provider’s order. Global Rationale: The nurse should complete the assessment to determine any respiratory abnormalities before using the pulse oximeter. Clients in DKA may not require a pulse oximeter as it does not provide information about acid-base balance or blood glucose levels. It reflects only the percentage of oxygen saturation of hemoglobin. If the RN determines the pulse oximeter is needed, the RN could delegate the task to the LPN. This would not require a healthcare provider’s order. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 30 Type: MCSA The nurse in interviewing a client observes changing of position frequently, wringing hands, and laughing at inappropriate times. Which of the following would be appropriate for the nurse to include in the assessment based on this information? 1. Anxiety assessment 2. Mental status testing 3. Attention deficit testing 4. Nutrition assessment Correct Answer: 1

Rationale 1: Body language and verbal responses can be key indicators of anxiety. If the patient exhibits anxiety during the interview, it may be a reflection of anxiety related to the situation or a need for further assessment. Rationale 2: Mental status testing would be indicated if the client demonstrates confusion. Rationale 3: The nurse does not conduct attention deficit testing. This is beyond the nurse’s scope of practice. Rationale 4: The observations by the nurse do not provide clues to the client’s nutritional state. Global Rationale: Body language and verbal responses can be key indicators of anxiety. If the patient exhibits anxiety during the interview it may be a reflection of anxiety related to the situation or a need for further assessment. One means used to further evaluate the anxiety is the use of an anxiety scale. Mental status testing would be indicated if the client demonstrates confusion. The nurse does not conduct attention deficit testing. This is beyond the nurse’s scope of practice. The observations by the nurse do not provide clues to the client’s nutritional state. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 31 Type: MCSA The nurse is admitting a client with a fractured hip. The client points to the painful hip and describes it as a constant throbbing. The nurse would include which of the following when continuing the pain assessment on this client? 1. Intensity, precipitating and relieving factors, impact on ADLs, and coping strategies 2. Intensity, quality, location, and impact on ADLs 3. Intensity, quality, pattern, and precipitating factors 4. Intensity, quality, precipitating and relieving factors, and impact on ADLs Correct Answer: 1 Rationale 1: Pain assessment should include data about the location, intensity, quality, pattern, precipitating factors, actions undertaken for relief of pain and effects, impact on ADLs, coping strategies and emotional responses. The description of client in the question already includes the quality, location, and pattern. Rationale 2: The client has already identified the quality and location of the pain. Rationale 3: The client has already identified the quality and pattern of the pain. Rationale 4: The client has already identified the quality of the pain.

Global Rationale: Pain assessment should include data about the location, intensity, quality, pattern, precipitating factors, actions undertaken for relief of pain and effects, impact on ADLs, coping strategies, and emotional responses. The description of the client in the question already includes the quality, location, and pattern. The client has already identified the quality and location of the pain. The client has already identified the quality, location, and pattern of the pain. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 32 Type: MCMA The nurse is conducting a class on hypertension, when a client asks what the numbers in the blood pressure mean. Which of the following statements would the nurse correctly use to answer the client’s question? Standard Text: Select all that apply. 1. “Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest.” 2. “Diastolic pressure is the arterial pressure between ventricular contractions.” 3. “Systolic pressure, indicated by the top number, is the result of the heart rate.” 4. “Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation.” 5. “Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts.” Correct Answer: 1,4 Rationale 1: “Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest.” The nurse should use terms the client can understand to respond to this question about blood pressure. “Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest,” and “Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation,” both explain blood pressure in terms the client should understand. Rationale 2: “Diastolic pressure is the arterial pressure between ventricular contractions.” While the statement “Diastolic pressure is the arterial pressure between ventricular contractions” is correct, these are not terms a client is likely to understand. Rationale 3: “Systolic pressure, indicated by the top number, is the result of the heart rate.” The systolic pressure is not a direct result of the heart rate.

Rationale 4: “Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation.” The nurse should use terms the client can understand to respond to this question about blood pressure. “Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation” is a statement that a client can understand. Rationale 5: “Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts.” The statement “Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts,” while a true statement, is not one that a lay person will understand. Global Rationale: The nurse should use terms the client can understand to respond to this question about blood pressure. “Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest,” and “Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation.” Both explain blood pressure in terms the client should understand. While the statement “Diastolic pressure is the arterial pressure between ventricular contractions” is correct, these are not terms a client is likely to understand. The systolic pressure is not a direct result of the heart rate. The statement “Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts,” while a true statement, is not one that a lay person will understand. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 33 Type: MCSA During a physical assessment the client asks the nurse repeatedly, “Is everything ok?” The nurse believes this client is demonstrating: 1. A poor self-concept. 2. Inappropriate affect. 3. Confusion. 4. Anxiety. Correct Answer: 4 Rationale 1: A client’s level of anxiety is reflected in speech, body language, and facial expressions. Repeatedly asking if “everything is ok” could be evidence of worry about the outcome of the examination. Rationale 2: Evidence of a poor self-concept would include poor personal hygiene practices. Rationale 3: An inappropriate affect would be demonstrated if the client responding inappropriately to a situation, such as laughter when discussing the death of a pet.

Rationale 4: Confusion would be demonstrated by a client who is not oriented to person, place, or time. Global Rationale: A client’s level of anxiety is reflected in speech, body language, and facial expressions. Repeatedly asking if “everything is ok” could be evidence of worry about the outcome of the examination. Evidence of a poor self-concept would include poor personal hygiene practices. An inappropriate affect would be demonstrated if the client responding inappropriately to a situation, such as laughter when discussing the death of a pet. Confusion would be demonstrated by a client who is not oriented to person, place, or time. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 34 Type: MCSA An older adult client has edema of the lower extremities despite being prescribed medication for this symptom. Which of the following should the nurse do first to assist this client? 1. Discuss the finding with the client’s healthcare provider. 2. Provide the client with support hose. 3. Review the client’s current medications. 4. Document the finding in the medical record. Correct Answer: 3 Rationale 1: The nurse should discuss the client’s current medications because older adult clients might be prescribed multiple medications, which can combine to produce dangerous side effects. The schedules for multiple medications may be confusing and result in overmedication, forgotten doses, negative side effects, or ineffectiveness of medication. Therefore, the nurse must conduct a thorough assessment of the client’s medication schedule and history. Rationale 2: The nurse should complete the client’s assessment before contacting the healthcare provider. Rationale 3: Providing the client with support hose might not be beneficial or indicated at this time. Rationale 4: Documenting the finding is important; however, it is not something that should be completed first. Global Rationale: The nurse should discuss the client’s current medications because older adult clients might be prescribed multiple medications, which can combine to produce dangerous side effects. The schedules for multiple medications may be confusing and result in overmedication, forgotten doses, negative side effects, or ineffectiveness of medication. Therefore, the nurse must conduct a thorough assessment of the client’s medication schedule and history. The nurse should complete the client’s assessment before contacting the healthcare provider.

Providing the client with support hose might not be beneficial or indicated at this time. Documenting the finding is important; however, it is not something that should be completed first. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter. Question 35 Type: MCSA The nurse is assessing a client who has had a cerebral vascular accident (CVA or stroke) and has difficulty with verbal expression, but no other deficits. What approach should the nurse use to assess this client’s level of pain? 1. The nurse asks the client’s family member to place a number on the client’s pain using a scale of 0 (no pain) to 10 (most pain), since the family member knows the client best. 2. The nurse considers the client’s behavior and vital signs and determines a number from the pain scale (0–10) based on these objective findings. 3. The nurse uses the Wong-Baker “FACES” pain rating scale. 4. The nurse reviews the previous pain assessments and makes a determination based on these findings. Correct Answer: 3 Rationale 1: The family member is not able to accurately identify the client’s pain level because pain is entirely subjective and personal. Rationale 2: The nurse incorporates objective findings into a thorough pain assessment, but pain is ultimately what the client says it is. Rationale 3: Pain is an entirely subjective and personal experience. Because this client has difficulty with verbal expression, but no other deficits, the nurse could use the “FACES” pain scale and ask the client to point to the picture that most closely correlates with current level of pain. Rationale 4: Previous assessments can help the nurse to determine a pattern of the client’ pain and pain control, but does not give the nurse any clues about the client’s current pain. Global Rationale: Pain is an entirely subjective and personal experience. Because this client has difficulty with verbal expression, but no other deficits, the nurse could use the “FACES” pain scale and ask the client to point to the picture that most closely correlates with current level of pain. The family member is not able to accurately identify the client’s pain level because pain is entirely subjective and personal. The nurse incorporates objective findings into a thorough pain assessment, but pain is ultimately what the client says it is. Previous assessments can help the nurse to determine a pattern of the client’ pain and pain control, but does not give the nurse any clues about the client’s current pain.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 8 Question 1 Type: MCSA The nurse is caring for a teenager and is assessing pain level with the vital signs. The client is reporting pain but when the nurse asks for a description of the pain the client says, “It just hurts. Why can’t I have something?” The nurse would choose to do which of the following next? 1. Leave the room and come back later. 2. Provide questions that require yes or no answers related to pain. 3. Ask the client what they would like to have for pain. 4. Continue with the vital signs assessment. Correct Answer: 2 Rationale 1: Leaving the room will not provide effective pain management. Rationale 2: People who are not feeling well or who are in pain may have difficulty with open-ended questions, such as “Describe….” The nurse may be better able to obtain an accurate description of their pain by having them respond to descriptive words. Rationale 3: Asking the client what she would like for pain is not appropriate without a complete assessment. Rationale 4: If the client is in pain, moving on to the vital signs will not yield additional information. Global Rationale: People who are not feeling well or who are in pain may have difficulty with open-ended questions, such as “Describe….” The nurse may be better able to obtain an accurate description of their pain by having them respond to descriptive words. Leaving the room will not provide effective pain management. Asking the client what she would like for pain is not appropriate without a complete assessment. If the client is in pain, moving on to the vital signs will not yield additional information. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain. Question 2 Type: MCSA The nurse is working at pain clinic and is preparing an orientation for new staff nurses. Which of the following definitions of pain would the nurse correctly choose to include in this orientation? Pain is:

1. Validated by the nurse determining the cause of the pain. 2. Unpleasant sensations, typically experienced upon movement. 3. Whatever the experiencing person says it is. 4. Very subjective so observations must be used to assess levels and intensity. Correct Answer: 3 Rationale 1: At times, the cause of the pain is not determined at the time the client reports it. The nurse’s role is not to validate the client’s report but to assess and assist in alleviating or managing the pain. Rationale 2: Pain involves unpleasant sensations, though not always limited to movement. Rationale 3: The most widely accepted definition of pain is the one offered by McCaffery: “whatever the experiencing person says it is, existing whenever he or she says it does” (McCaffery & Pasero, 1999, p. 5). Rationale 4: Pain is a subjective experience and the client’s report of pain must be trusted in order to effectively manage it. Global Rationale: The most widely accepted definition of pain is the one offered by McCaffery: “whatever the experiencing person says it is, existing whenever he or she says it does” (McCaffery & Pasero, 1999, p. 5). It involves unpleasant sensations, though not always limited to movement. At times, the cause of the pain is not determined at the time the client reports it. The nurse’s role is not to validate the client’s report but to assess and assist in alleviating or managing the pain. Pain is a subjective experience and the client’s report of pain must be trusted in order to effectively manage it. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 8.1: Provide a definition of pain. Question 3 Type: MCSA The client is in the triage area of the Emergency Department when a client arrives complaining of chest and arm pain. The client also reports jaw pain, but states that the chest pain hurts more. The nurse observes the client rubbing his left arm. The nurse suspects what type of pain? 1. Phantom pain 2. Radiating pain 3. Intractable pain 4. Cutaneous pain

Correct Answer: 2 Rationale 1: Phantom pain is a painful sensation perceived in an absent body part or a body part that is paralyzed. Rationale 2: The client is describing radiating pain, which has an origin in one part of the body and then spreads to other adjacent body parts. Rationale 3: Intractable pain does not respond to relief measures. Rationale 4: Cutaneous pain is pain experienced in the cutaneous tissues. Global Rationale: The client is describing radiating pain, which has an origin in one part of the body and then spreads to other adjacent body parts. Phantom pain is a painful sensation perceived in an absent body part or a body part that is paralyzed. Cutaneous pain is pain experienced in the cutaneous tissues. Intractable pain does not respond to relief measures. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1: Provide a definition of pain. Question 4 Type: MCSA The nurse is caring for two clients involved in a motor vehicle accident. Both clients required explorative abdominal surgery. Neither has received any pain medication in six hours and both have asked. However, one client is in greater distress than the other. Which pain theory is useful in explaining this phenomenon? The theory of: 1. Pattern. 2. Specificity. 3. Stress. 4. Gate control. Correct Answer: 4 Rationale 1: Pattern theory implies that the pattern of the stimulus is more important than the specific stimulus. It does not address the psychosocial component of pain. Rationale 2: Specificity theory holds that pain neurons are specific and unique and the specific pain neurons transport the sensations directly to the brain. Rationale 3: Stress does influence a client’s perception of pain but is not a specific theory.

Rationale 4: Gate control theory attempts to explain the involvement of the brain as well as nerve fibers in the pain experience. The involvement of the brain helps explain why painful stimuli are interpreted differently by people experiencing pain. Global Rationale: Gate control theory attempts to explain the involvement of the brain as well as nerve fibers in the pain experience. The involvement of the brain helps explain why painful stimuli are interpreted differently by people experiencing pain. Specificity theory holds that pain neurons are specific and unique and the specific pain neurons transport the sensations directly to the brain. Pattern theory implies that the pattern of the stimulus is more important than the specific stimulus. It does not address the psychosocial component of pain. Stress may impact a client’s perception of pain but is not a specific theory. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.2: Identify the physiology of pain. Question 5 Type: MCSA The nurse is caring for a client who denies having pain. The nurse has noticed the client grimacing and clenching his teeth when moving. The client’s spouse has asked the nurse why some people deny obvious pain. What response by the nurse is most appropriate? 1. “You should try to find out why your husband is denying the pain.” 2. “Have you talked to the healthcare provider about this?” 3. “Some people feel reporting their pain is a sign of weakness.” 4. “Maybe we are wrong and pain is not really bad.” Correct Answer: 3 Rationale 1: The spouse has sought assistance from the nurse. The nurse should attempt to respond to the inquiry. Rationale 2: The spouse is asking for information that is within the scope of nursing practice. There is no need to refer to the healthcare provider at this time. Rationale 3: Adult clients may deny the presence of pain. Sometimes the denial is an effort not to appear weak. Rationale 4: The nonverbal behaviors indicate the presence of pain. Global Rationale: Adult clients may deny the presence of pain. Sometimes the denial is an effort not to appear weak. The spouse has sought assistance from the nurse. The nurse should attempt to respond to the inquiry. The spouse is asking for information that is within the scope of nursing practice. There is no need to refer to the healthcare provider at this time. The nonverbal behaviors indicate the presence of pain.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.4: Discuss factors that influence pain. Question 6 Type: MCSA A client with chronic pain from spinal stenosis has asked the nurse for assistance with pain management. The client is well dressed and composed, with normal vital signs. The nurse observes that the client grimaces when sitting but rates the pain at only a 2. The nurse suspects which of the following? The client: 1. Needs to exercise instead of taking pain medication. 2. Is not in severe pain and does not need treatment. 3. Is getting better. 4. Has adapted to the pain and is able to control behaviors. Correct Answer: 4 Rationale 1: The plan of care to determine interventions cannot be determined at this point. Rationale 2: The client has stated that she is there for assistance with pain management, and the nurse has not completed the assessment. Rationale 3: Determining that the client’s condition is improving is beyond the scope of practice for the nurse. Rationale 4: People with chronic pain develop their individual coping styles to deal with pain, discomfort, or suffering. Also, physiologic responses may be marked in acute pain but because of central nervous system adaptation, physiologic responses are likely to be absent. Therefore, behavioral and physiologic responses are not good indicators of pain. Global Rationale: People with chronic pain develop their individual coping styles to deal with pain, discomfort, or suffering. Also, physiologic responses may be marked in acute pain but because of central nervous system adaptation, physiologic responses are likely to be absent. Therefore, behavioral and physiologic responses are not good indicators of pain. Determining that the client’s condition is improving is beyond the scope of practice for the nurse. The client has stated that she is there for assistance with pain management, and the nurse has not completed the assessment. The plan of care to determine interventions cannot be determined at this point. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.4: Discuss factors that influence pain.

Question 7 Type: MCSA The nurse is caring for two clients who both are in pain due to sickle cell anemia. One of the clients rates his pain as a 7 out of 10 (1 is no pain and 10 is the worst pain possible). This client is moving around easily and is eating well, but has asked for pain medicine. The nurse would choose which of the following actions? 1. Wait 30 minutes and see if the client is still requesting the pain medicine. 2. Administer half the ordered does of pain medication. 3. Administer the pain medication if it is has been longer than the ordered interval. 4. Notify the healthcare provider that the client is faking his pain. Correct Answer: 3 Rationale 1: Waiting to administer the medication is inappropriate and is an action that appears to negate the client’s reports. Rationale 2: Administration of only a portion of the ordered medication places the nurse in a position of prescribing medications and is outside the nurse’s scope of practice. Rationale 3: Since pain occurs whenever the experiencing person says it does and is whatever the experiencing person says it is, the nurse should accurately assess and treat the pain with the pain medication if that is what is ordered. Rationale 4: Notification to the healthcare provider that the patient is faking the pain is inappropriate as there is no evidence of this action. Global Rationale: Since pain occurs whenever the experiencing person says it does and is whatever the experiencing person says it is, the nurse should accurately assess and treat the pain with the pain medication if that is what is ordered. Waiting to administer the medication is inappropriate and is an action that appears to negate the client’s reports. Administration of only a portion of the ordered medication places the nurse in a position of prescribing medications and is outside the nurse’s scope of practice. Notification to the healthcare provider that the patient is faking the pain is inappropriate as there is no evidence of this action. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.4: Discuss factors that influence pain. Question 8 Type: MCSA The nurse is assessing a postoperative client that reports a pain level of 10 on a 1 to 10 scale. The client is grimacing and appears anxious. Which of the following actions should the nurse perform first?

1. Administer pain medication if it has been longer than the ordered interval. 2. Offer to call the pastoral service to provide spiritual counseling. 3. Obtain an order for an anti-anxiety medication. 4. Call the family to come in and stay with the client. Correct Answer: 1 Rationale 1: Pain needs to be well managed and pain should be assessed with vital signs. Pain is the 5th vital sign. Pain needs to be well managed with pain medications given on a scheduled basis, so that the pain does not get “out of control.” Once the pain is under control, the nurse can assess other factors influencing the client’s pain response. Rationale 2: Spiritual counseling may not be helpful if the pain is not managed effectively. Rationale 3: Relieving the anxiety may help in alleviating pain and should be considered with other forms of pain management. However, relieving anxiety will be easier if the pain is managed effectively. Rationale 4: The presence of family members may provide comfort to the client, but is not the priority intervention. Global Rationale: Pain needs to be well managed and pain should be assessed with vital signs. Pain is the 5th vital sign. Pain needs to be well managed with pain medications given on a scheduled basis, so that the pain does not get “out of control.” Once the pain is under control, the nurse can assess other factors influencing the client’s pain response. Spiritual counseling may not be helpful if the pain is not managed effectively. Relieving the anxiety may help in alleviating pain and should be considered with other forms of pain management. However, relieving anxiety will be easier if the pain is managed effectively. The presence of family members may provide comfort to the client, but is not the priority intervention. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain. Question 9 Type: MCMA The nurse is assessing a client admitted with severe abdominal pain. Which of the following would the nurse include as essential components of the pain assessment? Standard Text: Select all that apply. 1. Description of the pain 2. Temperature, pulse, respirations, and blood pressure

3. Pain intensity rating 4. Family medical history 5. Previous pain experience Correct Answer: 1,2,3,5 Rationale 1: Description of the pain. The nurse assessing the client will need to determine characteristics of the pain. These characteristics expressed by the client will aid in the management of the condition Rationale 2: Temperature, pulse, respirations, and blood pressure. The vital signs of the client reporting acute pain will likely provide supportive information concerning the pain being experienced. Rationale 3: Pain intensity rating. An integral part of the definition of pain is that it is what the individual reports it to be. The degree of intensity will be needed to determine the level of pain being experienced. The degree of pain intensity assessment will be a key component in the interventions being used to manage the pain. Rationale 4: Family medical history. While the family medical history is a component of a generalized health assessment it is not specific to the assessment of pain. Rationale 5: Previous pain experience. An individual’s past experience with pain is a determining factor in the ability to manage pain. Past experience will also impact reports of pain by the client. Global Rationale: The nurse assessing the client will need to determine characteristics of the pain. These characteristics expressed by the client will aid in the management of the condition. The vital signs of the client reporting acute pain will likely provide supportive information concerning the pain being experienced. An integral part of the definition of pain is that it is what the individual reports it to be. The degree of intensity will be needed to determine the level of pain being experienced. The degree of pain intensity assessment will be a key component in the interventions being used to manage the pain. While the family medical history is a component of a generalized health assessment it is not specific to the assessment of pain. An individual’s past experience with pain is a determining factor in the ability to manage pain. Past experience will also impact reports of pain by the client. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.5: Provide a definition of pain. Question 10 Type: MCSA The nurse is caring for a client complaining of a backache and administers ibuprofen. The client asks the nurse how the medication will help the pain. The nurse understands that ibuprofen’s effect occurs during which phase of nocioception? 1. Transduction

2. Transmission 3. Perception 4. Modulation Correct Answer: 1 Rationale 1: Since ibuprofen blocks the production of prostaglandin, it acts during the transduction phase. Rationale 2: In the transmission phase, the pain impulse travels from peripheral nerve fibers to the spinal cord to the brain stem and thalamus and ultimately, to the somatic sensory cortex. Rationale 3: Perception occurs when the client becomes aware of the pain. Rationale 4: Modulation is the process by which neurons in the brain stem send signals back down stimulating the release of neurotransmitters that can inhibit the ascending pain impulses. Global Rationale: Since ibuprofen blocks the production of prostaglandin, it acts during the transduction phase. In the transmission phase, the pain impulse travels from peripheral nerve fibers to the spinal cord to the brain stem and thalamus and ultimately, to the somatic sensory cortex. Perception occurs when the client becomes aware of the pain. Modulation is the process by which neurons in the brain stem send signals back down stimulating the release of neurotransmitters that can inhibit the ascending pain impulses. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.2: Identify the physiology of pain. Question 11 Type: MCSA A nurse working in a healthcare provider’s office is interviewing a client that reports experiencing daily migraines. The nurse decides to further assess the impact of the client’s pain. An appropriate choice of assessment tools would be which of the following? 1. Psychologic well-being inventory 2. Body Diagram tool 3. Intensity rating scale 4. Brief Pain Inventory Correct Answer: 4

Rationale 1: A psychological well-being inventory may yield information about the impact of pain on the client’s sense of well-being but is not designed to specifically assess the elements of pain. Rationale 2: A unidimensional tool such as the Body Diagram is useful for assessing pain severity at the time the client is experiencing pain. Rationale 3: A unidimensional tool such as the intensity rating scale is useful for assessing pain severity at the time the client is experiencing pain. Rationale 4: Migraine pain is chronic in nature and, therefore, a multidimensional tool such as the Brief Pain Inventory is the most useful for assessing two or more elements of the pain and the impact of pain on daily living. Global Rationale: Migraine pain is chronic in nature and, therefore, a multidimensional tool such as the Brief Pain Inventory is the most useful for assessing two or more elements of the pain and the impact of pain on daily living. A unidimensional tool such as the Body Diagram and intensity rating scale is useful for assessing pain severity at the time the client is experiencing pain. A psychological well-being inventory may yield information about the impact of pain on the client’s sense of well-being but is not designed to specifically assess the elements of pain. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain. Question 12 Type: MCSA The nurse understands amount of pain stimulation that is needed for an individual to feel pain is referred to as: 1. Pain threshold. 2. Pain tolerance. 3. Somatic interval. 4. Cephalgia reporting. Correct Answer: 1 Rationale 1: The pain threshold is the amount of pain stimulation a person requires in order to feel pain. Rationale 2: Pain tolerance refers to the ability of an individual to manage differing levels of discomfort. Rationale 3: Somatic interval is not legitimate pain terminology. Rationale 4: Cephalgia reporting is not legitimate pain terminology.

Global Rationale: The pain threshold is the amount of pain stimulation a person requires in order to feel pain. Pain tolerance refers to the ability of an individual to manage differing levels of discomfort. Somatic interval and cephalgia reporting are not legitimate pain terminology. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 8.2: Identify the physiology of pain. Question 13 Type: MCSA The nurse is examining a client is in the Emergency Department. The client has recently been discharged after a right above-the-knee amputation. The client tells the nurse that her right foot hurts. The nurse suspects what type of pain? 1. Phantom pain 2. Radiating pain 3. Intractable pain 4. Cutaneous pain Correct Answer: 1 Rationale 1: The client is describing phantom pain, which is a painful sensation perceived in an absent body part or a body part that is paralyzed. Rationale 2: Radiating pain has an origin in one part of the body and then spreads to other adjacent body parts. Rationale 3: Intractable pain does not respond to relief measures. Rationale 4: Cutaneous pain is pain experienced in the cutaneous tissues. Global Rationale: The client is describing phantom pain, which is a painful sensation perceived in an absent body part or a body part that is paralyzed. Radiating pain has an origin in one part of the body and then spreads to other adjacent body parts. Intractable pain does not respond to relief measures. Cutaneous pain is pain experienced in the cutaneous tissues. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Describe the different types of pain. Question 14

Type: MCMA The nurse is assessing a client admitted with chronic back pain. Which of the following would the nurse associate with this type of pain? Standard Text: Select all that apply. 1. Sudden onset 2. Interferes with daily activities 3. Lower intensity 4. Prolonged in duration 5. Sharp elevations in body temperature Correct Answer: 2,4 Rationale 1: Sudden onset. Chronic pain is recurring and persists for a period of 6 months or longer. Rationale 2: Interferes with daily activities. Chronic pain invades the life of a client. The daily activities of the client with chronic pain are impacted. Rationale 3: Lower intensity. The level of intensity experienced by the client with chronic pain will vary. It is not necessarily low in intensity. Rationale 4: Prolonged in duration. By definition, chronic pain lasts for a period of 6 months or longer. Rationale 5: Sharp elevations in body temperature. Sharp elevations in vital signs are not associated with chronic pain. Global Rationale: Chronic pain is recurring and persists for a period of 6 months or longer. It invades the life of a client, impacting the daily activities of the client. The level of intensity experienced by the client with chronic pain will vary. It is not necessarily low in intensity. Sharp elevations in vital signs are not associated with chronic pain. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Describe the different types of pain. Question 15 Type: MCSA The parents of a 13-month-old infant requiring a veinipuncture for laboratory studies ask the nurse what they can do to help with pain during the procedure. Which of the following would be the best action for the nurse to take?

1. Have the parents leave the area during the procedure. 2. Tell the parents to touch and reassure the infant during the procedure. 3. Wait until the infant is asleep to do the procedure. 4. Administer an analgesic 30 minutes before the procedure. Correct Answer: 2 Rationale 1: Having the parents leave the area may cause the infant to react very strongly to the painful stimulus. Rationale 2: The nurse understands that the presence of supportive people may affect the infant’s perception of the severity of the pain, and provide reassurance and security. Rationale 3: Being awakened from a sound sleep by painful stimuli may cause the infant to react very strongly. Rationale 4: Administering an analgesic is inappropriate as the infant is not yet experiencing the pain, and after the relatively quick procedure is over, the infant should no longer feel any pain. Global Rationale: The nurse understands that the presence of supportive people may affect the infant’s perception of the severity of the pain, and provide reassurance and security. Administering an analgesic is inappropriate as the infant is not yet experiencing the pain, and after the relatively quick procedure is over, the infant should no longer feel any pain. Having the parents leave the area may cause the infant to react very strongly to the painful stimulus, as will being awakened from a sound sleep by painful stimuli. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.4: Discuss factors that influence pain. Question 16 Type: MCSA A recently licensed nurse states, “My client keeps saying he is in pain. I don’t believe him because I had the same surgery last year and didn’t feel nearly as bad as he claims.” What response by the more experienced nurse is most appropriate? 1. “It sounds as if your client is a drug seeker.” 2. “You should contact the healthcare provider.” 3. “I would call the nursing supervisor for this one.” 4. “Pain differs from person to person.” Correct Answer: 4

Rationale 1: There is no evidence that this client is drug seeking. Rationale 2: Contact with the healthcare provider is premature at this time. Rationale 3: Contact with the nursing supervisor is premature at this time. Rationale 4: Pain has been defined as “whatever the experiencing person says it is, existing whenever he or she says it does.” Pain reports will vary between people. Global Rationale: Pain has been defined as “whatever the experiencing person says it is, existing whenever he or she says it does.” Pain reports will vary between people. There is no evidence that this client is drug seeking. Contact with the healthcare provider and nursing supervisor is premature at this time. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.4: Discuss factors that influence pain. Question 17 Type: MCMA The nurse is performing an assessment on a 23-year-old client who is being seen for chronic back pain. During the assessment, which of the following findings can be anticipated? Standard Text: Select all that apply. 1. Increased pulse rate 2. Increased respiratory rate 3. Normal pulse rate 4. Normal blood pressure 5. Diaphoresis Correct Answer: 3,4 Rationale 1: Increased pulse rate. The heart rate of the client in chronic pain will be within normal limits. The heart rate will more likely be increased in the client with acute pain. Rationale 2: Increased respiratory rate. The respiratory rate of the client experiencing chronic pain will most likely be within normal levels. The respiratory rate will most likely increase in the client with acute pain. Rationale 3: Normal pulse rate. The pulse rate of the client experiencing chronic pain will likely be within normal limits. Elevations in pulse rate are seen in clients experiencing acute pain.

Rationale 4: Normal blood pressure. The blood pressure findings in the client experiencing chronic pain will most likely be within normal limits. Elevations are most often seen in clients experiencing acute pain. Rationale 5: Diaphoresis. Diaphoresis is seen most likely in the client in acute pain, not chronic pain. Global Rationale: The heart rate, respiratory rate, and blood pressure of the client in chronic pain will likely be within normal limits. The heart rate, respiratory rate, and blood pressure will more likely be increased in the client with acute pain. Diaphoresis is seen most likely in the client in acute pain, not chronic pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.2 Identify the physiology of pain Question 18 Type: MCMA The nurse is caring for a 3-year-old child who has been hospitalized for internal fixation of a fractured arm. The nurse is considering nonpharmacological pain management techniques to implement. What interventions should be included in the plan of care? Standard Text: Select all that apply. 1. Offer a glucose-coated pacifier. 2. Sit with the child and allow her to “blow bubbles.” 3. Explain to the child the cause of the pain. 4. Teach the use of guided imagery. 5. Hold the child. Correct Answer: 2,5 Rationale 1: Offer a glucose coated pacifier. The use of a glucose-coated pacifier is most effective with an infant in the management of pain. Rationale 2: Sit with the child and allow her to “blow bubbles.” Blowing bubbles is an age-appropriate activity for the preschool-age child. The child can be encouraged to “blow the pain” away. Rationale 3: Explain to the child the cause of the pain. A child at the age of 3 is too young to grasp a discussion of the causes of the pain being experienced. Rationale 4: Teach the use of guided imagery. Age-appropriate guided imagery is not a successful nonpharmacological means to manage pain in a preschool-age child. This may be helpful for the school-age child.

Rationale 5: Hold the child: The preschool-age child will find comfort in being held during the pain. Global Rationale: The use of a glucose-coated pacifier is most effective with an infant in the management of pain. Blowing bubbles is an age-appropriate activity for the preschool-age child. The child can be encouraged to “blow the pain” away. A child at the age of 3 is too young to grasp a discussion of the causes of the pain being experienced. Age-appropriate guided imagery is not a successful nonpharmacological means to manage pain in a preschool-age child. This may be helpful for the school-age child. The preschool-age child will find comfort in being held during the pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain. Question 19 Type: MCMA A client has multiple fractures following a motor vehicle accident. One of the client outcomes of the nurse’s plan of care includes reducing the perception of pain. Which of the following nursing interventions would apply to reaching this outcome? Standard Text: Select all that apply. 1. Offering a selection of musical CDs 2. Assisting with guided imagery 3. Administering Demerol (Meperidine) intravenously 4. Providing instruction on deep breathing techniques 5. Administering an anti-inflammatory medication Correct Answer: 1,2,4 Rationale 1: Offering a selection of musical CDs. The use of music is a means to assist the client to shift the focus from the pain to something else. This will help in reducing the perception of pain. Rationale 2: Assisting with guided imagery. Guided imagery allows the client to focus on a calmer, more positive place or sensation. This allows the focus to divert from the pain. This is a means to reduce the perception of pain. Rationale 3: Administering Demerol (Meperidine) intravenously. The administration of narcotic analgesics does not work to diminish the perception. These medications work to reduce the transmission of the pain to the client’s nerve sensors.

Rationale 4: Providing instruction on deep breathing techniques. The use of therapeutic techniques will reduce the client’s sensation of pain being experienced. Rationale 5: Administering an anti-inflammatory medication. The medication will reduce discomfort by reducing the inflammation. This method does not reduce the perception of the pain. The medications reduce inflammation, thus reducing the incidence of pain, not the perception of it. Global Rationale: The use of music, guided imagery, and deep breathing techniques are means to assist the client to shift the focus from the pain to something else. This will help in reducing the perception of pain. The administration of narcotic analgesics does not work to diminish the perception. These medications work to reduce the transmission of the pain to the client’s nerve sensors. Anti-inflammatory medication will reduce discomfort by reducing the inflammation. This method does not reduce the perception of the pain. The medications reduce inflammation, thus reducing the incidence of pain, not the perception of it. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.4: Discuss factors that influence pain. Question 20 Type: MCSA A 45-year-old client continues to request intravenous pain medications 4 days after being placed in skeletal traction due to a complex fracture of the hip. While giving report to the next shift, the nurse who cared for the client during the day states, “I just do not know why he still needs medication 4 days after surgery. The client we had last month with the same type situation did not need any medication after 2 days.” Which of the following responses by a nursing peer is the best example of being a client advocate? 1. “I just think this client needs more because of his age.” 2. “Have you tried getting the doctor to order oral pain medications to see if they work?” 3. “Wouldn’t you want all of the pain medication you could have if you were in traction?” 4. “Everyone does not have the same pain perception or response to a similar injury.” Correct Answer: 4 Rationale 1: Pain threshold does not appear to change specifically with aging. Rationale 2: Traditionally oral pain medications are used to manage less severe reports of pain. The client in the scenario has uncontrolled pain. The client in the scenario has uncontrolled pain. The best course of action for the nurse is to educate the colleague about the individuality of the pain experience. Rationale 3: A nurse’s personal attitudes or perceptions should not influence the care that is provided to a client.

Rationale 4: Based on the definition by McCaffery & Pasero pain is “whatever the experiencing person says it is, existing whenever he or she says it does.” This definition supports each client’s need for individualized pain management approaches. Global Rationale: Based on the definition by McCaffery & Pasero, pain is “whatever the experiencing person says it is, existing whenever he or she says it does.” This definition supports each client’s need for individualized pain management approaches. Pain threshold does not appear to change with aging. Traditionally oral pain medications are used to manage less severe reports of pain. The client in the scenario has uncontrolled pain. The client in the scenario has uncontrolled pain. The best course of action for the nurse is to educate the colleague about the individuality of the pain experience. A nurse’s personal attitudes or perceptions should not influence the care that is provided to a client. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.4: Discuss factors that influence pain Question 21 Type: MCSA A nursing student is reviewing the home medications of a client who has just been admitted with chronic back pain. When asked by the nursing instructor why there is a tricyclic antidepressant on the client’s list, which response by the student is most likely the accurate reason? 1. “I would think having chronic pain would make the client depressed.” 2. “It may be to prevent depression due to physical limitations.” 3. “This type of medication can help inhibit painful stimuli.” 4. “The client is at risk for suicidal thoughts related to the chronic pain.” Correct Answer: 3 Rationale 1: This medication is not being used to prevent or manage depression. Rationale 2: This medication is not being used to prevent or manage depression. Rationale 3: Tricyclic antidepressants can inhibit the reuptake of norepinephrine and serotonin. This would assist with the modulation phase of pain response by decreasing the pain stimuli response. Rationale 4: This medication is not being used to reduce the incidence of suicidal thoughts. Global Rationale: Tricyclic antidepressants can inhibit the reuptake of norepinephrine and serotonin. This would assist with the modulation phase of pain response by decreasing the pain stimuli response. This medication is not being used to prevent depression, manage depression, or reduce the incidence of suicidal thoughts.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.2: Identify the physiology of pain. Question 22 Type: MCSA The nursing student is discussing an assigned client’s pain responses with the nursing instructor. The student reports feeling amazed about how the client has continued to avoid taking any analgesics only hours after surgery. What response by the nursing instructor is indicated? 1. “Sometimes clients just don’t need any analgesics.” 2. “Have you seen any nonverbal cues that might indicate the client is experiencing pain?” 3. “We will need to contact the healthcare provider to report the client’s continued refusal of analgesics.” 4. “Do the client’s vital signs indicate the client is experiencing pain?” Correct Answer: 2 Rationale 1: “Sometimes clients just don’t need any analgesics.” A variety of factors will influence a client’s perception of pain and willingness to receive analgesics. Rationale 2: “Have you seen any nonverbal cues that might indicate the client is experiencing pain?” The nurse will need to promote a comprehensive assessment of the client’s pain experience. Nonverbal behaviors will need to be considered. Some clients may be stoic with the pain experience. Rationale 3: “We will need to contact the healthcare provider to report the client’s continued refusal of analgesics.” There is no need to contact the healthcare provider at this time. Rationale 4: “Do the client’s vital signs indicate the client is experiencing pain?” The client’s vital signs should be considered in the assessment of pain but they are not the priority consideration Global Rationale: A variety of factors will influence a client’s perception of pain and willingness to receive analgesics. The nurse will need to promote a comprehensive assessment of the client’s pain experience. Nonverbal behaviors will need to be considered. Some clients may be stoic with the pain experience. There is no need to contact the healthcare provider at this time. The client’s vital signs should be considered in the assessment of pain but they are not the priority consideration. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.4: Discuss factors that influence pain.

Question 23 Type: MCMA The nurse is performing a physical assessment on a client with undiagnosed back pain. The client is unable to communicate verbally. Which of the following vital sign values would indicate to the nurse that the client is in acute pain? Standard Text: Select all that apply. 1. Temperature of 100.6 degrees: 2. Pulse rate 94 3. Respiratory rate 32 4. Blood pressure 158/92 5. Facial grimacing Correct Answer: 2,3,4,5 Rationale 1: Temperature of 100.6 degrees. The client may be diaphoretic with acute pain, but not directly as a result of a low-grade temperature. Rationale 2: Pulse rate 94. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. Rationale 3: Respiratory rate 32. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. Rationale 4: Blood pressure 158/92. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. Rationale 5: Facial grimacing. Facial grimacing may be noted in the expressions of the client experiencing acute pain. Global Rationale: The client may be diaphoretic with acute pain, but not directly as a result of a low-grade temperature. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. Facial grimacing may be noted in the expressions of the client experiencing acute pain. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.2: Describe the physiology of pain. Question 24

Type: MCSA A client with a history of cardiac problems is brought to the emergency room by the paramedics with a tentative diagnosis of myocardial infarction (MI, or “heart attack”). The paramedic tells the nurse that the client had pain in the jaw area that was not relieved with nitroglycerin. The client asks the nurse how jaw pain is related to having a “heart attack.” The nurse’s best explanation is: 1. “The doctors would rather treat you as a cardiac client until they find out why the nitroglycerin did not work.” 2. “Sometimes cardiac pain is not just in your chest, but in your jaws, arms or back.” 3. “You may have been so stressed that you clenched your jaws and not realized if you had any chest pain or not.” 4. “It may not be related, but cardiac pain is so serious to investigate and treat.” Correct Answer: 2 Rationale 1: It is inappropriate for the nurse to indicate the healthcare provider is treating the client in a manner without certainty. Rationale 2: Referred pain may result when pain is felt in tissues that are not in close proximity to the primary cause or site of the pain. This may be especially true of cardiac pain. It may be exhibited in the jaw, shoulders, arms, or back. Rationale 3: Clenching teeth would not be linked to chest pain. Rationale 4: While cardiac pain is serious, this response does not meet the level of client questioning. Global Rationale: Referred pain may result when pain is felt in tissues that are not in close proximity to the primary cause or site of the pain. This may be especially true of cardiac pain. It may be exhibited in the jaw, shoulders, arms, or back. It is inappropriate for the nurse to indicate the healthcare provider is treating the client in a manner without certainty. Clenching teeth would not be linked to chest pain. While cardiac pain is serious, this response does not meet the level of client questioning. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.2: Identify the physiology of pain. Question 25 Type: MCSA A 12-year-old client is brought to the emergency room after falling on his arm during a football game. When the nurse tells the client that she is going to administer pain medication through the intravenous line, the client begins to scream and wave his unhurt arm. The parents ask the nurse why their child is behaving this way. The nurse’s best response would be:

1. “He is just immature for his age.” 2. “I am sure he is just scared.” 3. “It looks like he may have hurt his head during the fall.” 4. “He may be remembering another time when he got a shot.” Correct Answer: 4 Rationale 1: There is no information to indicate that the client is immature for age. Rationale 2: Assuming the child is just “scared” is not something the nurse can be “sure” of, as it is never safe to assume anything as a definite. Rationale 3: There is no information to indicate the presence of a head injury. Rationale 4: A client’s nervous system responds to pain, but many times there are also behavioral responses. A client’s pain reaction may be a behavioral response to a similar or previous situation when pain was experienced. This is a learned response and method of coping with the pain. Many children remember getting a “shot” for pain, or getting an immunization. Seeing the syringe and/or needle may trigger this pain reaction. Global Rationale: A client’s nervous system responds to pain, but many times there are also behavioral responses. A client’s pain reaction may be a behavioral response to a similar or previous situation when pain was experienced. This is a learned response and method of coping with the pain. Many children remember getting a “shot” for pain, or getting an immunization. Seeing the syringe and/or needle may trigger this pain reaction. Assuming the child is just “scared” is not something the nurse can be “sure” of, as it is never safe to assume anything as a definite. There is no information to indicate the presence of a head injury or that the client is immature for age. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 8.4: Describe factors influencing pain. Question 26 Type: MCSA A nurse is orienting to a new position in an infant nursery. When the healthcare provider is preparing to perform a circumcision on a 2-day-old newborn who was born 2 weeks early, the nurse asks about the administration of pain medication prior to the procedure. The healthcare provider states: “Newborns do not have pain at this age, so why should we give any medication?” The nurse’s best response would be: 1. “I would think it would make the parents feel better to know it had been given.” 2. “I am going to have to report you to the ethics board.”

3. “Pain transmission has been documented in infants of this age.” 4. “What will it hurt to just go ahead and give it?” Correct Answer: 3 Rationale 1: The emotional well-being of the parents is of interest but does not address the question being asked. Rationale 2: Reporting the healthcare provider to the ethics board is not indicated as the healthcare provider has not acted in a manner consistent with a violation of ethics. Rationale 3: Research has changed the perception that infants do not feel pain. Performing procedures that may induce pain necessitates that pain management interventions should be implemented. An infant may have pain interventions based upon behavioral responses exhibited. Rationale 4: Asking for the medication to be given does not meet the question being asked. Global Rationale: Research has changed the perception that infants do not feel pain. Performing procedures that may induce pain necessitates that pain management interventions should be implemented. An infant may have pain interventions based upon behavioral responses exhibited. The emotional well-being of the parents is of interest but does not address the question being asked. Reporting the healthcare provider to the ethics board is not indicated as the healthcare provider has not acted in a manner consistent with a violation of ethics. Asking for the medication to be given does not meet the question being asked. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.2: Identify the physiology of pain Question 27 Type: MCSA Which of the following assessment data will be most reflective of a client’s pain response following open-heart surgery? 1. Family report of pain 2. Response from the client based on use of a pain tool 3. Observations of the client’s behaviors while asleep 4. Measurement of vital signs Correct Answer: 2 Rationale 1: The family may perceive the client to be in pain when she is not.

Rationale 2: The use of a standardized pain tool that has been discussed with the client preoperatively will provide the most useful data. Rationale 3: Observations of behavior while the client is asleep may indicate pain, but use of a tool while the client is awake would be more accurate. Rationale 4: Vital sign changes may be a result of the body’s response to surgery and not just specifically to pain. Global Rationale: The use of a standardized pain tool that has been discussed with the client preoperatively will provide the most useful data. The family may perceive the client to be in pain when she is not. Observations of behavior while the client is asleep may indicate pain, but use of a tool while the client is awake would be more accurate. Vital sign changes may be a result of the body’s response to surgery and not just specifically to pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain. Question 28 Type: MCSA The nurse is interviewing a 75-year-old client who is in the healthcare provider’s office for complaints of joint pain. The client verbalizes that the pain has been present for a few years. When planning interview questions to ask concerning the pain, the nurse recognizes which of the following? 1. Clients start to complain of many types of pain as they age. 2. The joint pain is probably not the real reason the client is in the office. 3. The client is most likely depressed. 4. Older adults frequently avoid seeking treatment for their pain. Correct Answer: 4 Rationale 1: Older clients typically do not complain of pain. They may fear that the treatment prescribed may limit their independence. Rationale 2: There is no other information given to suggest that the client has another cause for the visit. Rationale 3: There is no other information given to suggest that the client is depressed. Rationale 4: The older adult may perceive pain as part of the aging process. They may fear that the treatment prescribed may limit their independence.

Global Rationale: The older adult may perceive pain as part of the aging process. They typically do not complain of pain. They may fear that the treatment prescribed may limit their independence. There is no other information given to suggest that the client is depressed or has another cause for the visit. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain. Question 29 Type: MCSA A 19-year-old Arab male is in the hospital for a ruptured appendix. His parents are at the bedside the majority of his waking hours. The nurse caring for him during the day observes that he denies any pain during the day shift. The night nurse reported that the client had requested pain medication every 4 hours during the night. The nurse considers the most probable explanation for this to be: 1. The night nurse had more time to spend with the client. 2. The client must be afraid or lonely at night and is trying to get attention. 3. The client may not report pain in the presence of his parents based on their influence or cultural beliefs. 4. The client was asking for medication at night to help him sleep. Correct Answer: 3 Rationale 1: There is no information provided to indicate the night nurse spent more time with the client than the day/evening shifts. Rationale 2: There is no indication the client is afraid or lonely. Rationale 3: A client may have ethnic or cultural beliefs that influence the response to pain. Some clients may be verbal and open, while some clients may choose to be quiet and suffer with the pain. The presence of family members, especially adult family members in this situation, may influence the reporting of pain. The client may have not wanted to contradict the perceived parental expectations of how an adult Arab male was to respond to pain. Rationale 4: There is no indication the client is experiencing difficulty sleeping. Global Rationale: A client may have ethnic or cultural beliefs that influence the response to pain. Some clients may be verbal and open, while some clients may choose to be quiet and suffer with the pain. The presence of family members, especially adult family members in this situation, may influence the reporting of pain. The client may have not wanted to contradict the perceived parental expectations of how an adult Arab male was to respond to pain. There is no information provided to indicate the night nurse spent more time with the client than the day/evening shifts. There is no indication the client is afraid or lonely. Many healthcare providers routinely order hypnotic medications. There is no indication the client is experiencing difficulty sleeping.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.4: Describe factors influencing pain. Question 30 Type: MCSA The nurse has completed a shift assessment on a client who has terminal breast cancer with extensive metastasis. The client tells the nurse, “Nothing helps the pain.” What best describes the pain being experienced by the client? 1. The client is experiencing referred pain. 2. The client is experiencing intractable pain. 3. The client is experiencing retractable pain. 4. The client is experiencing radiating pain. Correct Answer: 2 Rationale 1: Referred pain refers to pain that is felt in an area that is physically distant to the affected area. Rationale 2: Intractable pain refers to pain that is not controllable. It is often associated with an advanced malignancy. Rationale 3: Retractable pain does not exist. Rationale 4: Radiating pain refers to pain that extends to surrounding areas of the body. Global Rationale: Intractable pain refers to pain that is not controllable. It is often associated with an advanced malignancy. Referred pain refers to pain that is felt in an area that is physically distant to the affected area. Retractable pain does not exist. Radiating pain refers to pain that extends to surrounding areas of the body. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 8.2: Identify the physiology of pain. Question 31 Type: SEQ The nurse is preparing to complete the admission assessment for a client who is being admitted to the acute care facility for complaints of severe pain. As the nurse plans actions relating to this task, the following steps will be taken. Organize in order the actions that should be taken by the nurse.

Standard Text: Click and drag the options below to move them up or down. Choice 1. Contact the healthcare provider. Choice 2. Discuss the unit routine with the client and family. Choice 3. Ask the client when the pain first began. Choice 4. Ask the client what helps to relieve the pain. Choice 5. Assess the client’s past coping methods for pain throughout her life. Correct Answer: 3,4,5,2,1 Rationale 1: Contact the healthcare provider. The healthcare provider will need to be contacted about the current condition of the client but this cannot be completed until the client has been assessed. The assessment information will allow the nurse to provide information to the healthcare provider. Rationale 2: Discuss the unit routine with the client and family. The client and family need to have information provided concerning unit policies but this is not an immediate task. Management of the client’s admission data collection takes precedence. Rationale 3: Ask the client when the pain first began. Determining the duration of the pain is the most important step that must be taken by the nurse. This information will provide a guide for the remaining information that will be sought from the client. Rationale 4: Ask the client what helps to relieve the pain. The client in pain has likely been employing methods to manage the discomfort at home. Determining the measures being taken away from the acute care facility will help to lead the health care team in managing the current pain. This information can also be used to help indicate the severity of pain being experienced. Rationale 5: Assess the client’s past coping methods for pain throughout her life. An individual’s methods of coping with pain will help to determine her tolerance and ability to manage current pain. This information is needed but does not take priority over assessing the duration of the pain being experienced or the methods being used to manage the current pain. Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 9 Question 1 Type: MCSA The nurse has calculated the BMI (body mass index) of a 54-year-old client who weighs 169 pounds and is 6 feet in height, and has obtained a result of 23. The nurse would correctly interpret this results as which of the following? 1. Mild malnutrition 2. Normal 3. Overweight 4. Obese class 1 Correct Answer: 2 Rationale 1: Mild malnutrition is considered a BMI of 17–18.49. Rationale 2: Normal BMI ranges between 18.5 and 24.9. Rationale 3: Overweight BMIs are between 25 and 29.9. Rationale 4: Obese class 1 BMIs are between 30 and 34.9. Global Rationale: Adult BMI classification places a result of 23 within the range of normal, which includes BMIs between 18.5 and 24.9. Mild malnutrition is considered a BMI of 17–18.49. Overweight BMIs are between 25 and 29.9. Obese class 1 BMIs are 30–34.9. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.1: Define nutritional health. Question 2 Type: MCSA The nurse is using a dietary recall tool to obtain a nutritional history on a client. The nurse must recognize the greatest limitation of using this assessment tool is which of the following? 1. Clients do not remember liquid intake from day to day. 2. It does not reflect food preferences of the client.

3. Clients do not provide reliable nutritional information. 4. It does not reflect occasional food habits. Correct Answer: 4 Rationale 1: The diet recall does not reflect all flood and liquids taken in during the previous 24 hours or longer. Rationale 2: A 24-hour dietary recall does not need to reflect food preferences of the client to provide the needed information. Rationale 3: Although a 24-hour dietary recall is not the most reliable method to obtain information, it is considered somewhat reliable. Rationale 4: The food habits that are employed occasionally are not the focus of a 24-hour dietary recall. It is used to determine recent intake. Global Rationale: One limitation of the 24-hour dietary recall is that it does not, or may not, reflect food habits that occur occasionally but not on the day recalled. It is not the most reliable way of obtaining information since it does rely on the client’s memory; however, it is considered somewhat reliable and a useful tool for nutritional assessment. It does not need to reflect food preferences. The diet recall does reflect all food and liquids taken in during the previous 24 hours, or longer period, if asked. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.6: Describe existing validated nutritional assessment tools. Question 3 Type: MCSA The nurse is obtaining tricep skinfold measurements on a client. Which of the following locations would the nurse correctly use for this assessment? 1. Midpoint of the arm between the scapula and the elbow 2. Two inches and centered below the scapula 3. One inch around the umbilicus 4. Lateral aspect of thigh Correct Answer: 1 Rationale 1: Tricep skinfold measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow.

Rationale 2: Tricep skinfold measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not 2 inches and centered below the scapula. Rationale 3: Tricep skinfold measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not at the umbilical region. Rationale 4: Tricep skinfold measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not in the lateral aspect of thigh. Global Rationale: Tricep skinfold measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow. The remaining answers are not tricep skinfolds. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4: Identify physical and laboratory parameters utilized in a nutrition assessment Question 4 Type: MCSA The nurse using the body mass index (BMI) to assess weight in a client should understand which of the following limitations of this method? 1. There is lack of correlation of the values in the BMI table with those in height-weight tables. 2. Assumption that all individuals have equal body composition at each given weight 3. BMI is difficult to accurately calculate. 4. The BMI’s use to determine the risk for obesity is reduced in individuals who are on reduced calorie diets. Correct Answer: 2 Rationale 1: There is lack of correlation of the values in the BMI table with those in height-weight tables. A clinical limitation of body mass index is the assumption that all individuals have equal body composition at each given weight. This has not been found to be true. Rationale 2: Assumption that all individuals have equal body composition at each given weight. A clinical limitation of body mass index is the assumption that all individuals have equal body composition at each given weight. This has not been found to be true. The amount of muscle mass, body fat, and bone mineral content varies according to high level of fitness, race, and ethnic differences. Rationale 3: BMI is difficult to accurately calculate. BMI is easily calculated using the standard formula and has a relationship with height and weight.

Rationale 4: The BMIs use to determine the risk for obesity is reduced in individuals who are on reduced calorie diets. The BMI is not used to determine the risk for obesity. The use of the tool is not limited by an individual’s current caloric intake. Global Rationale: A clinical limitation of body mass index is the assumption that all individuals have equal body composition at each given weight. This has not been found to be true. The amount of muscle mass, body fat, and bone mineral content varies according to high level of fitness, race, and ethnic differences. BMI is easily calculated using the standard formula and has a relationship with height and weight. The BMI is not used to determine the risk for obesity. The use of the tool is not limited by an individual’s current caloric intake. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4: Identify physical and laboratory parameters utilized in a nutrition assessment. Question 5 Type: MCSA The nurse is performing a nutritional assessment and is concerned about undernutrition in a client. Which of the following conditions would cause the nurse to suspect this nutritional disorder? 1. Renal failure 2. Hypertension 3. Wound that will not heal 4. Delayed menopause Correct Answer: 3 Rationale 1: Renal failure. There are many causes of kidney failure which are not related to nutrition. Rationale 2: Hypertension. Hypertension often accompanies overnutrition. Rationale 3: Wound that will not heal. Undernutrition can lead to delayed growth, compromised immune status, poor wound healing, muscle loss, physical and functional decline, and lack of proper development. Rationale 4: Delayed menopause. Delay in menopause is not a nutritional concern. Global Rationale: Undernutrition can lead to delayed growth, compromised immune status, poor wound healing, muscle loss, physical and functional decline, and lack of proper development. Overnutrition results from excesses in nutrient intake or stores and can manifest itself in conditions such as obesity, hypertension, hypercholesterolemia, or toxic levels of stored vitamins or minerals. There are many causes of kidney failure that are not related to nutrition. Delay in menopause is not a nutritional concern. Cognitive Level: Remembering

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.1: Define nutritional health. Question 6 Type: MCSA The nurse is assessing a 12-month-old child and needs to determine length. The nurse would correctly use which of the following procedures to obtain this information? 1. Get assistance to measure the child from head to toe in prone position. 2. Wait until the child is sleeping and hold the child upright in front of a tape measure attempting for the best accuracy possible. 3. Place the child in a supine position and measure from the crown of the head to the heel while holding the legs straight. 4. Have the mother to assist the child in standing in front of a tape measure. Correct Answer: 3 Rationale 1: Get assistance to measure the child from head to toe in prone position. The nurse may enlist help from others to measure, but the measurement is from head to heel, not head to toe, and not in prone position. Rationale 2: Wait until the child is sleeping and hold the child upright in front of a tape measure attempting for the best accuracy possible. It is incorrect to hold a client in a standing position to obtain a height measurement, either with the client awake or asleep. Rationale 3: Place the child in a supine position and measures from the crown of the head to the heel while holding the legs straight. Recumbent length is obtained on persons who cannot stand freely for height measurements. The length is measured using a device, or by having the person lie flat in the supine position and measuring from the crown of the head to the heel with toes pointed upward and knees straight. Rationale 4: Have the mother to assist the child in standing in front of a tape measure. It is incorrect to hold a client in a standing position to obtain a height measurement, either with the client awake or asleep. Global Rationale: Recumbent length is obtained on persons who cannot stand freely for height measurements. The length is measured using a device, or by having the person lie flat in the supine position and measuring from the crown of the head to the heel with toes pointed upward and knees straight. It is incorrect to hold a client in a standing position to obtain a height measurement, either with the client awake or asleep. The nurse may enlist help from others to measure, but the measurement is from head to heel, not head to toe, and not in prone position. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet history. Question 7 Type: MCSA The nurse is interviewing a 20-year-old client who is 14 weeks pregnant and seeking prenatal care. She tells the nurse that she likes to eat ice and occasionally eats dirt. The nurse should anticipate which of the following laboratory studies to be ordered? 1. Folate level 2. Calcium levels 3. Plasma lead level 4. Hair analysis Correct Answer: 3 Rationale 1: Folate level. Folate and calcium levels may not be affected by PICA. Rationale 2: Calcium levels. Folate and calcium levels may not be affected by PICA. Rationale 3: Plasma lead level. Lead levels should be obtained in pregnant women reporting PICA because the soil eaten can be a source of environmental contamination. Rationale 4: Hair analysis. Hair analysis may yield information about other issues but is not appropriate given the above scenario. Global Rationale: PICA refers to the craving and ingestion of nonfood substances. Lead levels should be obtained in pregnant women reporting PICA because the soil eaten can be a source of environmental contamination. Folate and calcium levels may not be affected. Hair analysis may yield information about other issues but is not appropriate given the above scenario. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.2: Outline risk factors that affect nutritional health status. Question 8 Type: MCSA The nurse is admitting a 69-year-old client with a possible hip fracture. The client is overweight, so the nurse understands that there is an increased likelihood risk for which of the following? 1. Decubiti

2. Degenerative joint disease 3. Chronic pain 4. Stroke Correct Answer: 2 Rationale 1: Decubiti. Overweight clients may be at an increased risk for the development of decubiti but this is not a direct finding associated with a hip fracture. Rationale 2: Degenerative joint disease. Overweight and obesity are risk factors for degenerative joint disease and functional and mobility problems as a result of the stressors on the joints from the excess weight. Rationale 3: Chronic pain. There is no relationship between the client’s weight, possible hip fracture and the presence of chronic pain. Rationale 4: Stroke. There is inadequate information to support the risk for stroke. Global Rationale: Overweight and obesity are risk factors for degenerative joint disease and functional and mobility problems. Overweight clients may be at an increased risk for the development of decubiti but this is not a direct finding associated with a hip fracture. There is no relationship between the client’s weight, possible hip fracture and the presence of chronic pain. There is inadequate information to support the risk for stroke. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 9.2: Outline risk factors that affect nutritional health status. Question 9 Type: MCSA The nurse is teaching a newly diagnosed diabetic about appropriate serving sizes for foods. The nurse would include which of the following estimates for a single serving of meat? 1. One cup 2. Size of a balled fist 3. Five ounces 4. Three ounces Correct Answer: 4 Rationale 1: One cup. One cup is larger than the recommended portion size for animal proteins.

Rationale 2: Size of a balled fist. A balled fist represents a cup-sized serving, which is too large for a portion of animal proteins. Rationale 3: Five ounces. The recommended portion size for animal proteins is 3 ounces. Rationale 4: Three ounces. The recommended portion size for animal proteins is 3 ounces, or a portion approximately the same size as a deck of cards. Global Rationale: The recommended portion size for animal proteins is 3 ounces, which can be correctly estimated by comparing to the size of a deck of cards. The size of a balled fist is too large for a serving of animal proteins. Five ounces exceeds the recommend amount for protein intake during a single serving. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet history data. Question 10 Type: MCMA The nurse has reviewed the assessment findings for a recently admitted client. The nurse notes the client’s dietary intake of the vitamin B complex to be lacking. Which of the findings confirm this deficiency? Standard Text: Select all that apply. 1. Loss of fat 2. Muscle wasting 3. Hyporeflexia 4. Spoon nails 5. Ataxia Correct Answer: 3,5 Rationale 1: Loss of fat. A series of vitamins make up the vitamin B complex. These vitamins are found in meat products and whole grains. A loss of fat is associated with a deficiency in protein or overall caloric intake. Rationale 2: Muscle wasting. A series of vitamins make up the vitamin B complex. These vitamins are found in meat products and whole grains. A loss of muscle tissue is associated with a lack of protein intake. Rationale 3: Hyporeflexia. A series of vitamins make up the vitamin B complex. These vitamins are found in meat products and whole grains. Thiamine is also known as Vitamin B1. It is responsible for nervous system functioning. Thiamine deficiency is associated with hyporeflexia. Rationale 4: Spoon nails. Spoon nails are noted with a lack of iron intake.

Rationale 5: Ataxia. A series of vitamins make up the vitamin B complex. These vitamins are found in meat products and whole grains. Vitamin B12 is also referred to as Cobalamin. Vitamin B12 deficiencies are associated with ataxia. Global Rationale: A series of vitamins make up the vitamin B complex. These vitamins are found in meat products and whole grains. Thiamine is also known as vitamin B1. It is responsible for nervous system functioning. Thiamine deficiency is associated with hyporeflexia. Vitamin B12 is also referred to as Cobalamin. Vitamin B12 deficiencies are associated with ataxia. A lack of caloric intake and protein deficiency is associated with a loss of fat. Protein deficiencies are also associated with muscle wasting. Spoon nails are seen with iron deficiencies. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 9.6: Differentiate between normal and abnormal findings in a nutritional assessment. Question 11 Type: HOTSPOT The nurse is using waist circumference to assess overnutrition in an adult female. Place a horizontal line across the figure to indicate correct placement for the measurement tape.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The waist circumference may be used to assess for overnutrition in a client. It is not useful for determining overnutrition in a pregnant female or in the client with ascites. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. 9: Determine specific nutritional assessment techniques and tools appropriate for unique stages in the life span. Question 12 Type: MCMA A Bioelectrical Impedance Analysis (BIA) is being performed on a client. Which of the following is associated with this test? Standard Text: Select all that apply. 1. Instruct the client to be NPO for 6 to 8 hours prior to the assessment. 2. Instruct the client to discontinue all vitamin and mineral supplementation for 24 hours prior to the assessment. 3. Instruct the client to lie in a supine position during the assessment. 4. Place electrodes on the dorsal surface of the client’s foot. 5. Place electrodes on the dorsal surface of the client’s hand. Correct Answer: 3,4,5 Rationale 1: Instruct the client to be NPO for 6 to 8 hours prior to the assessment. Altered hydration and altered skin temperature will cause measurement error by altering electrical current flow. Clients should be well hydrated when employing BIA technology, or dehydration will slow conductivity and give a falsely high body fat measurement.

Rationale 2: Instruct the client to discontinue all vitamin and mineral supplementation for 24 hours prior to the assessment. Calculations are based on the knowledge that muscle and fluids have a higher electrolyte and water content than does fat and thus conduct electrical current differently. Discontinuation of vitamin and mineral supplementation does not impact test findings. Rationale 3: Instruct the client to lie in a supine position during the assessment. During the assessment the client will be instructed to lie in a supine position. Rationale 4: Place electrodes on the dorsal surface of the client’s foot. Electrodes are placed on the dorsal surface of the client’s foot for the test. Rationale 5: Place electrodes on the dorsal surface of the client’s hand. Electrodes are placed on the dorsal surface of the client’s hand for the test. Global Rationale: Bioelectrical impedance analysis (BIA) is a noninvasive tool for assessing body composition employing principles of electroconduction through water, muscle, and fat. In traditional BIA, electrodes are placed on the dorsal surfaces of the right foot and hand with the client in the supine position on a nonconductive surface. Calculations are based on the knowledge that muscle and fluids have a higher electrolyte and water content than does fat and thus conduct electrical current differently. Altered hydration and altered skin temperature will cause measurement error by altering electrical current flow. Clients should be well hydrated when employing BIA technology, or dehydration will slow conductivity and give a falsely high body fat measurement. Clients cannot be placed as NPO status prior to the testing for 6 to 8 hours as this would alter the readings. The use of vitamin and mineral supplementation will not impact test findings. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.6: Describe existing validated nutritional assessment tools. Question 13 Type: MCSA The nurse is assessing a 9-month-old girl during a well-child checkup. She is quiet and does not demonstrate much social interaction. The child appears petite and unusually small for her age. The nurse plots her height and weight on a growth chart and sees that the baby was in the 50th percentile for weight at age 6 months, and the baby is in the 5th percentile at this visit. The nurse suspects which of the following conditions in this child? 1. Congestive heart failure 2. Dehydration 3. Undernutrition 4. Hypoglycemia Correct Answer: 3

Rationale 1: Congestive Heart Failure. There is no indication the client has cardiac problems. Rationale 2: Dehydration.There is no indication the client’s hydration status is compromised. Rationale 3: Undernutrition. Undernutrition can lead to growth faltering, compromised immune status, poor wound healing, muscle loss, physical and functional decline, and lack of proper development. The client’s weight changes indicate a lack of nutritional intake. Rationale 4: Hypoglycemia. There is no indication the client has alterations in endocrine function. Global Rationale: Undernutrition, also called malnutrition, describes health effects of insufficient nutrient intake or stores. Children who drop at least 2 percentile bands are at risk for undernutrition. There are no indications the client has cardiac-health–related concerns. Hypoglycemia is not applicable in this situation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment into the nursing care process. Question 14 Type: MCSA The nurse is performing anthropometric measurements on a client in the clinic setting. The nurse would use which of the following definitions of this term when explaining this to the client? 1. The assessment is obtained by subtracting the height in centimeters from the weight in pounds and multiplying by 2. 2. The assessment includes any scientific measurement of the body for nutritional analysis. 3. The measurements include the use of growth chart evaluations to plot height and weight. 4. The measurement estimates skinfold thicknesses. Correct Answer: 2 Rationale 1: The assessment is obtained by subtracting the height in centimeters from the weight in pounds and multiplying by 2. Anthropometric measurements are specific body measurements such as height, weight, and measurement of body fat. It does not utilize the calculation of weight and height in this manner. Rationale 2: The assessment includes any scientific measurement of the body for nutritional analysis. Anthropometric measurements are any scientific measurements of the body. Rationale 3: The measurements include the use of growth chart evaluations to plot height and weight. Anthropometric measurements are any scientific measurements of the body. They are not simply growth chart evaluations.

Rationale 4: The measurement estimates skinfold thicknesses. Anthropometric measurements are any scientific measurements of the body. They may include height, weight, measurement of body fat, and muscle composition. They may include measurements of skinfold thickness, not estimations. Global Rationale: Anthropometric measurements are any scientific measurements of the body. They may include height, weight, measurement of body fat, and muscle composition. They may include measurements of skin fold thickness. They are not simply growth chart evaluations or calculations using combinations of numbers. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.9: Determine specific nutritional assessment techniques and tools appropriate for unique stages in the life span. Question 15 Type: MCSA The nurse is calculating the percent weight change of a 40-year-old female, weighing 156 pounds 1 month ago, and 140 pounds on current examination. The nurse would correctly record: 1. 5% 2. 10% 3. 12% 4. 14.3% Correct Answer: 2 Rationale 1: 5%: A 5% weight loss would result in a weight of approximately 146 lb. Rationale 2: 10%: A weight loss of 15% would result in a weight of approximately 141 lb. Rationale 3: 12%: A weight loss of 12% would result in a weight of approximately 137 lb. Rationale 4: 14.3%: A weight loss of 14.3% would result in a weight of approximately 134 lb. Global Rationale: The formula for calculating percent weight change is: [156 lbs – 140 lbs/156 lbs] x 100. These calculations yield an answer of 10 percent. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet history data.

Question 16 Type: MCMA The nurse is preparing an inservice for staff on the risk factors for poor nutritional health. Which of the following would the nurse include as risk factors for overnutrition? Standard Text: Select all that apply. 1. Alcohol abuse 2. Sedentary lifestyle 3. Excess intake of fat, sugar, calories, or nutrients 4. Lack of knowledge about food preparation 5. Lack of knowledge about portion sizes Correct Answer: 2,3,4,5 Rationale 1: Alcohol abuse. Alcohol abuse is statistically linked to undernutrition. Rationale 2: Sedentary lifestyle. The lack of calorie burning activity of a sedentary lifestyle is associated with overnutrition and weight gain. Rationale 3: Excess intake of fat, sugar, calories, or other nutrients. Is commonly linked to overnutrition and weight gain. Rationale 4: Lack of knowledge about food preparation. Food preparation may result in overnutrition as “unhealthy” techniques may be employed. Rationale 5: Lack of knowledge about portion sizes. Portion control is key in the management of weight gain and loss. Lack of knowledge about portion control may result in over eating. Global Rationale: Overnutrition results from excesses in nutrient intake or stores and can manifest itself in conditions such as obesity, hypertension, hypercholesterolemia, or toxic levels of stored vitamins or minerals. Sedentary lifestyles are linked to overnutrition. Individuals who are inactive typically require a lower caloric intake and will burn a lower number of calories. An excessive intake of fat, sugar, calories, and other nutrition places an individual at risk for overnutrition. Individuals who have a lack of knowledge concerning food preparation may fix and consume foods that are not nutritionally balanced, possibly increasing their risk for overnutrition. Knowledge of recommended portion sizes helps to ensure adequate nutritional intake. A lack of portion size recommendations may result in overeating. Alcohol abuse is statistically linked to undernutrition. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.2: Outline risk factors that affect nutritional health status.

Question 17 Type: MCMA The graduate nurse in orientation notices that a dietician evaluates each postoperative client’s chart. They know that this is done primarily to: Standard Text: Select all that apply. 1. Meet a regulatory agency requirement. 2. Determine nutritional needs. 3. Check for any cultural dietary considerations. 4. Check to see if there are any potential food-drug interactions. 5. Assess for overnutrition. Correct Answer: 2,3,4 Rationale 1: Meet a regulatory agency requirement. Although the collection of dietary information may be needed to meet the requirements of a regulatory agency, it is not the priority action in this situation. Rationale 2: Determine nutritional needs. The assessment of a client’s nutritional health requires a collaborative approach by multidisciplines. Postoperative clients may have different nutritional needs to promote healing. Rationale 3: Check for any cultural dietary considerations. The nutritional selections suggested need to incorporate a client’s religious or cultural considerations, or the plan will not be a feasible one for the client. Rationale 4: Check to see if there are any potential food-drug interactions. As medications may change postoperatively, assessing for potential interactions with foods may prevent a problem in the future. Rationale 5: Assess for overnutrition. Concerns regarding overnutrition are not the most important for the client who has recently had surgery. Global Rationale: The evaluation of the client’s postoperative chart by the dietician is done to assess the nutritional needs of the client. Clients in the postoperative phase of their care are attempting to heal. Healing is facilitated by adequate nutritional intake. The incorporation of cultural dietary preferences will best ensure that the client eat the foods provided by the facility and promote adequate nutritional intake. The potential for fooddrug interactions must be included in the plan of care. Medications may be changed in the postoperative period warranting the assessment. Determination of these potential interactions will help to prevent complications in the client. The review of the postoperative chart may be a requirement of certain regulatory agencies but is not the most important factor. The risk for overnutrition may exist for the client but is not the primary focus for the assessment of the chart during the postoperative period. Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet history. Question 18 Type: MCSA An 80-year-old male client is brought to the emergency room by his son with a preliminary diagnosis of dehydration. The client is agitated. When the nurse asks the client to open his mouth for an oral exam, the client yells, “You don’t need to look in my mouth to see what is wrong with me!” The nurse’s best rationale for looking in his mouth is: 1. That a complete physical exam must be performed. 2. To assess for poorly-fitting dentures. 3. To assess for oral lesions. 4. To assess mucous membranes. Correct Answer: 4 Rationale 1: A complete physical exam must be performed. The completion of a physical examination is needed during the admission process, but it is not the most important reason for the oral examination for this client. Rationale 2: To assess for poorly-fitting dentures. The client’s poor nutritional status may be the result of poorly fitting dentures. This will need to be determined, but it is not the most important reason for completing this portion of the assessment. Rationale 3: To assess oral lesions. The presence of oral lesions may impact the ability of the client to have adequate nutritional intake. The assessment for the presence of the lesions important but not as important as the determination of the presence and degree of dehydration. Rationale 4: To assess mucus membranes. The condition of the mucous membranes is the most important rationale for the assessment of the oral cavity. The determination of the presence and degree of dehydration is key in beginning the client’s treatment. Global Rationale: Poor dental health may contribute to malnutrition. If a client has oral ulcerations in the mouth, poorly-fitting dentures, decaying or loose teeth, it may be painful to eat or drink. This could cause a client to have a limited oral intake of food and fluids. Assessment of mucous membranes for moistness and color is part of an assessment when considering dehydration. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.8: Differentiate between normal and abnormal findings in a nutritional assessment. Question 19 Type: MCSA A 24-year-old client visits the healthcare provider office for a routine yearly gynecological exam. The nurse is providing education to the client. The client asks for an explanation of why the nurse recommended that she take a multivitamin that contains folic acid. The nurse’s best response would be: 1. “If you become pregnant, you will already be taking folic acid.” 2. “Everyone should take vitamin supplements.” 3. “Folic acid can help with your chances of getting pregnant.” 4. “Most people do not get enough folic acid.” Correct Answer: 1 Rationale 1: “If you become pregnant, you will already be taking folic acid.” The client in the scenario is of childbearing age. Folic acid is essential for all women of childbearing potential. It is important for a healthy outcome of a pregnancy. Some women are not aware of being pregnant at first and are not already taking folic acid. By suggesting a supplement, it will already be present in the body if the woman becomes pregnant. Rationale 2: “Everyone should take vitamin supplements.” Not everyone needs vitamin supplements or have low folic acid levels if their dietary intake is balanced and appropriate. Rationale 3: “Folic acid can help with your chances of getting pregnant.” Folic acid is a vitamin. Not everyone needs vitamin supplements or have low folic acid levels if their dietary intake is balanced and appropriate. Rationale 4: “Most people do not get enough folic acid.” Not everyone needs vitamin supplements or have low folic acid levels if their dietary intake is balanced and appropriate. Global Rationale: Folic acid is essential for all women of childbearing potential. It is important for a healthy outcome of a pregnancy. It does not help a person become pregnant. Some women are not aware of being pregnant at first and are not already taking folic acid. By suggesting a supplement, it will already be present in the body if the woman becomes pregnant. Not everyone needs vitamin supplements or have low folic acid levels if their dietary intake is balanced and appropriate. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.3: Discuss the objectives described in Healthy People 2020 which relate to nutrition. Question 20 Type: MCSA

A nurse is preparing to review an overweight client’s food recall diary for the past week. Which of the following choices would be most helpful when teaching a client about recommended portion sizes? 1. Measuring cups 2. Food cups 3. Everyday items such as a deck of cards 4. Plastic containers Correct Answer: 3 Rationale 1: Measuring cups. Having a client use measuring cups, food scales, and plastic containers can be helpful when preparing foods at home, but not realistic when estimating portion sizes at restaurants. Rationale 2: Food cups. Having a client use measuring cups, food scales and plastic containers can be helpful when preparing foods at home, but not realistic when estimating portion sizes at restaurants. Rationale 3: Everyday items such as a deck of cards. By using everyday items such as a deck of cards to determine meat sizes or a golf ball to determine a tablespoon measurement, a client can learn to visually estimate appropriate portions. This visual teaching method may be a useful and easy approach for clients. Rationale 4: Plastic containers. Having a client use measuring cups, food scales, and plastic containers can be helpful when preparing foods at home, but not realistic when estimating portion sizes at restaurants. Global Rationale: Determining portion sizes is difficult for most clients. When keeping a diet diary or doing a diet recall, the client may be confused if the number of meals is adequate but he continues to gain weight. Having a client use measuring cups, food scales, and plastic containers can be helpful when preparing foods at home, but not realistic when estimating portion sizes at restaurants. By using everyday items such as a deck of cards to determine meat sizes or a golf ball to determine a tablespoon measurement, a client can learn to visually estimate appropriate portions. This visual teaching method may be a useful and easy approach for clients. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment into the nursing care process. Question 21 Type: MCSA An overweight female client is reluctant to get on the scales at the healthcare provider’s office. She verbalizes that she does not want to know how much she actually weighs. The nurse’s best response would be: 1. “The doctor requires all of her clients to be weighed.”

2. “This information is very important. If you step on the scales, I will just write your weight down and not say it out loud.” 3. “I really do not like it either, but it has to be done.” 4. “We can just use your weight from your visit last year.” Correct Answer: 2 Rationale 1: “The doctor requires all of her clients to be weighed.” Explaining that the weight is required does not really meet the concerns being voiced by the client. Rationale 2: “This information is very important. If you step on the scales, I will just write your weight down and not say it out loud.” A client’s weight is part of the anthropometric measurements. The height, weight, and body fat and muscle composition are part of these measurements. By using these values with a physical assessment, a client’s nutritional status may be evaluated. Promoting the confidentiality of the procedure may help to reassure and calm the client. Rationale 3: “I really do not like it either, but it has to be done.” Forcing the client is a violation of rights. Rationale 4: “We can just use your weight from your visit last year.” Using a weight that is a year old will not accurately reflect a current trend or change. The data can still be gathered for a nutritional assessment and the client’s wishes met by measuring the client’s weight without verbalizing what it is. Global Rationale: A client’s weight is part of the anthropometric measurements. The height, weight, and body fat and muscle composition are part of these measurements. By using these values with a physical assessment, a client’s nutritional status may be evaluated. Forcing the client is a violation of rights. Using a weight that is a year old will not accurately reflect a current trend or change. The data can still be gathered for a nutritional assessment and the client’s wishes met by measuring the client’s weight without verbalizing what it is. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment into the nursing care process. Question 22 Type: MCSA The nurse has collected data on clients who have visited a health fair in the mall. Which of the following clients is most in need of a detailed nutritional assessment? 1. A 21-year-old female who has just begun college and has lost 5 pounds in the first semester 2. A 2 year old whose mother stated that he seems to be growing faster than she can buy him clothes 3. A 50-year-old male who reported that he lost 10 pounds in 6 weeks without even trying

4. A 35-year-old female who has gained 15 pounds in a year after the birth of her first child Correct Answer: 3 Rationale 1: A 21-year-old female who has just begun college and has lost 5 pounds in the first semester. The female that just began college has had activity and nutrition changes. Rationale 2: A 2 year old whose mother stated that he seems to be growing faster than she can buy him clothes. Toddlers experience growth spurts that are normal physiological processes. Rationale 3: A 50-year-old male who reported that he lost 10 pounds in 6 weeks without even trying. Unintentional weight loss is considered clinically significant and requires further assessment. The cause is not readily apparent and may be due to a disease process. Rationale 4: A 35-year-old female who has gained 15 pounds in a year after the birth of her first child. In the first year after the birth of a child a woman may increase body weight as a result of diet, activity, and hormonal changes. Global Rationale: Unintentional weight loss is considered clinically significant and requires further assessment. The cause is not readily apparent and may be due to a disease process. The female that just began college has had activity and nutrition changes. The 2 year old seems to be growing sufficiently and the 35-year-old female has had recent body changes. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.8: Differentiate between normal and abnormal findings in a nutritional assessment. Question 23 Type: MCSA A group of college student athletes from the volleyball team have reported concerns about the reports regarding their weight and nutritional status. The reports were based on BMI (body mass index) values. The team’s healthcare provider that collected the data and sent the reports decided to change their recommendations based on which explanation? 1. BMI reports are best used for athletes who are engaging in body-building activities. 2. BMI classifications should be used only on older adults. 3. BMI classifications do not take into account racial or physical variations. 4. Nutritional status of a college student should be evaluated using skinfold measurements. Correct Answer: 3

Rationale 1: BMI reports are best used for athletes who engage in body-building activities. BMI classifications do not take into account physical variations or athletic levels of individuals. Rationale 2: BMI classifications should be used only on older adults. The BMI is a tool that may be used on adults, not just older adults. Rationale 3: BMI classifications do not take into account racial or physical variations. The BMI should not be used exclusively to evaluate weight or nutritional recommendations. It is not reflective of variations of body fat, muscle size or bone mineral content, racial or athletic level of an individual. Rationale 4: Nutritional status of a college student should be evaluated using skinfold measurements. Skinfold measurement alone may not provide an overall nutrition evaluation. Global Rationale: The BMI should not be used exclusively to evaluate weight or nutritional recommendations. It is not reflective of variations of body fat, muscle size or bone mineral content, racial or athletic level of an individual. Using this tool in addition to other nutritional screenings such as skinfold measurement, physical assessment and interviewing will provide the best overall evaluation and recommendation base. The cost of using the tool is not a consideration. The tool is for use in adults, not just older adults. Skinfold measurement alone may not provide an overall nutrition evaluation. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9.9: Determine specific nutritional assessment techniques and tools appropriate for unique stages in the life span. Question 24 Type: MCSA A 78-year-old female client is in the healthcare provider’s office for a routine physical exam. She asks for an explanation of why skinfold measurements are not done on her anymore. The nurse’s best response would be: 1. “Those tests are no longer recommended to assess BMI.” 2. “As a person ages, the test is not as accurate.” 3. “The BMI (body mass index) test is easier to use.” 4. “A detailed dietary history will give us the information that we need.” Correct Answer: 2 Rationale 1: “Those tests are no longer recommended to assess BMI.” Expressing to the client that the “tests are no longer recommended” does not meet the request for information. In addition, the test is not used to determine BMI.

Rationale 2: “As a person ages, the test is not as accurate.” The subcutaneous fat distribution and total body fat composition change as an adult ages. The reference values for older adults and suggested locations of skinfold measurements requires further investigation and data collection to be accurate. Rationale 3: “The BMI (body mass index) test is easier to use.” The ease of the test is not the reason for the change in the assessments being performed. Rationale 4: “A detailed dietary history will give us the information that we need.” A diet history is an important part of a nutritional assessment, but does not give body composition values. Global Rationale: The subcutaneous fat distribution and total body fat composition change as an adult ages. The reference values for older adults and suggested locations of skinfold measurements require further investigation and data collection to be accurate. Skinfold measurements are not recommended to provide BMI information. They are intended to assess subcutaneous fat distribution. The reference values are still used in adults, but variations such as race, gender, and fitness level need to be considered. The BMI is easier to use, but does not give as detailed data about actual body fat and muscle mass. The ease of the test is not the basis for the changes in assessment being reported by the client. A diet history is an important part of a nutritional assessment, but does not give body composition values. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.9: Determine specific nutritional assessment techniques and tools appropriate for unique stages in the life span. Question 25 Type: MCSA The nurse is collecting nutritional intake information from a client. The nurse does not feel the client is being forthcoming and honest with the intake self-reports. Which of the following factors may be associated with inaccurate reporting of dietary intake? 1. Female gender 2. Male gender 3. Higher socioeconomic levels 4. Lower educational levels Correct Answer: 4 Rationale 1: Female gender. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels.

Rationale 2: Male gender. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels. Rationale 3: Higher socioeconomic levels. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels. Rationale 4: Lower educational levels. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels. Global Rationale: Some clients may underreport portions of the nutritional history during the data collection process. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels. Additionally, alcohol and drug use are frequently underreported. A nonjudgmental approach during the nutritional history will provide an environment conducive to full answers by the client. Cognitive Level: Understanding Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment into the nursing care process. Question 26 Type: MCSA The community health nurse is planning a program for a group of African American senior citizens. Which of the following facts should be included in the presentation? 1. The prevalence of overnutrition is greatest in African American males. 2. Hypertension is highest in the African American population. 3. Adults living at the poverty line have the greatest risk for undernutrition. 4. Iron deficiency anemia is a prevalent problem in the African American population. Correct Answer: 2 Rationale 1: The prevalence of overnutrition is greatest in African American males. The prevalence of overnutrition is highest in the Mexican American male. Rationale 2: Hypertension is highest in the African American population. Hypertension is highest in the African American population.

Rationale 3: Adults living at the poverty line have the greatest risk for undernutrition. The risk for overnutrition is most associated with a lower socieoeconomic status and reduced levels of education Rationale 4: Iron deficiency anemia is a prevalent problem in the African American population. Iron deficiency anemia is not documented as a prevalent problem in the African American population Global Rationale: The prevalence of overnutrition is highest in the Mexican American male. Hypertension is highest in the African American population. The risk for overnutrition is most associated with a lower socieoeconomic status and reduced levels of education. Iron deficiency anemia is not documented as a prevalent problem in the African American population. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.2: Outline risk factors that affect nutritional health status. Question 27 Type: MCSA The nurse is collecting data from a client at the ambulatory care clinic. During the meeting, the client asks the nurse about using height and weight tables to determine his ideal weight. What response by the nurse is most appropriate? 1. “It is important for your health that you closely adhere to the recommendations of height and weight tables to avoid weight-related complications.” 2. “Height and weight tables are highly subjective.” 3. “Using height and weight tables can be problematic because they are often inaccurate.” 4. “Height and weight tables have significant limitations for predicting weight status of an individual.” Correct Answer: 4 Rationale 1: “It is important for your health that you closely adhere to the recommendations of height and weight tables to avoid weight related complications.” Height-weight tables have been used in the past to assess body weight in adults, but are no longer a standard. Use of such height-weight tables has the same limitations as does use of BMI as a sole indicator of weight status. Rationale 2: “Height and weight tables are highly subjective.” Height-weight tables have been used in the past to assess body weight in adults, but are no longer a standard. Use of such height-weight tables has the same limitations as does use of BMI as a sole indicator of weight status. Rationale 3: “Using height and weight tables can be problematic as they are often inaccurate.” Heightweight tables have been used in the past to assess body weight in adults, but are no longer a standard. Use of such height-weight tables has the same limitations as does use of BMI as a sole indicator of weight status.

Rationale 4: “Height and weight tables have significant limitations for predicting weight status of an individual.” Height-weight tables have been used in the past to assess body weight in adults, but are no longer a standard. Use of such height-weight tables has the same limitations as does use of BMI as a sole indicator of weight status. Global Rationale: Height-weight tables have been used in the past to assess body weight in adults, but are no longer a standard. Use of such height-weight tables has the same limitations as does the use of BMI as a sole indicator of weight status. Differences in body composition go largely unaccounted for and the clinician must remember to assess each person for these individual differences. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.6: Describe existing validated nutritional assessment tools Question 28 Type: MCMA The school nurse is discussing dietary concerns with student members of the track team. Which of the following statements indicates the need for further instruction? Standard Text: Select all that apply. 1. “There are no differences in the percentage of body fat needed by girls and boys during the teen years.” 2. “The lower I can get my body fat percentage, the better.” 3. “The body fat percentages needed by females is higher than that of males.” 4. “There are no absolute standards for body fat percentages needed by men and women.” 5. “Persons having body fat percentages greater than 20% are at an increased risk for illness.” Correct Answer: 1,2,5 Rationale 1: “There are no differences in the percentage of body fat needed by girls and boys during the teen years.” The recommended body fat percentages for females is greater than that of males. Rationale 2: “The lower I can get my body fat percentage, the better.” The absolute minimum levels of body fat are still being studied; however, experts do believe that there are minimum body fat percentages. Rationale 3: “The body fat percentages needed by females is higher than that of males.” A range of 12% to 20% body fat in men and 20% to 30% in women has been suggested for health. Rationale 4: “There are no absolute standards for body fat percentages needed by men and women.” Research aimed at development of future standards and references for body fat percentage will address the

relationship between BMI and body fat percentage and allow the nurse a clearer assessment of body composition traits associated with health risks. Age-specific recommendations are also needed. Rationale 5: “Persons having body fat percentages greater than 20% are at an increased risk for illness.” Standards of body fat percentage that are associated with health or morbidity and mortality have not been established. Many sources agree that a minimum essential body fat percentage exists. Global Rationale: During the teen years differing percentages of body fat are needed by girls and boys. Females need a higher percentage of body fat. A range of 12% to 20% body fat in men and 20% to 30% in women has been suggested for health. The absolute minimum levels of body fat are still being studied; however, experts do believe that there are minimum body fat percentages. Research aimed at development of future standards and references for body fat percentage will address the relationship between BMI and body fat percentage and allow the nurse a clearer assessment of body composition traits associated with health risks. Age-specific recommendations are also needed. Standards of body fat percentage that are associated with health or morbidity and mortality have not been established. Many sources agree that a minimum essential body fat percentage exists. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9.4: Identify physical and laboratory parameters utilized in a nutrition assessment. Question 29 Type: MCSA When interviewing a 68-year-old male client, the nurse discovers a list of 23 herbal and vitamin supplements that are being consumed by the client each day. Which response by the client indicates the need for further nutritional teaching by the nurse at this visit? 1. “I have been taking all of them for over 20 years now.” 2. “My doctor in my old town recommended most of them.” 3. “My wife also takes the same things.” 4. “I know that I do not eat right all of the time, so they will keep me healthy.” Correct Answer: 4 Rationale 1: “I have been taking all of them for over 20 years now.” The length of time the client has been taking a potentially excessive level of vitamin supplements is not the greatest concern. The larger concern is the potential belief that they will protect him from illness by offsetting nutritional deficits. The age of the client will increse the potential dangers of this practice as the older adult body may change how the supplements affect the body. Rationale 2: “My doctor in my old town recommended most of them.” The current physican of record will need notification to review the medications being taken. They may impact currently prescribed medications.

Rationale 3: “My wife also takes the same things.” The health of the spouse may be impacted by oversupplementation but the greatest current concern is the potential risks being faced by the client in the scenario. Rationale 4: “I know that I do not eat right all of the time, so they will keep me healthy.” Dietary intake is the best means to meet nutritional requirements. Oversupplementation may present health-related concerns. Global Rationale: Oversupplementation of herbs, vitamins, minerals, and sports products may be dangerous. The older adult has physiologic body changes that may change how the supplements affect the body. Many supplements have effects on medications the client may be taking, whether they are over-the-counter or prescribed medications. Use of supplements is not intended to replace healthy nutrition on a routine basis. This client needs education before there are problems. The other responses may require further investigation and an assessment of overall nutrition, but these responses do not indicate a current problem. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.8: Differentiate between normal and abnormal findings in a nutritional assessment. Question 30 Type: HOTSPOT The nursing instructor is evaluating the knowledge of the student in locating the landmarks for assessing tricep skinfold measurements. Mark with and label the correct landmark for this technique.

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The tricep skinfold (TSF) is the site most often used to estimate subcutaneous fat because of easy access to this measurement in most situations. Tricep measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4: Identify physical and laboratory parameters utilized in a nutrition assessment. Question 31 Type: MCSA The nurse is preparing to conduct a focused interview on a client who reports a recent weight gain. Which of the following inquiries is most appropriate? 1. “Are you eating more than you should?” 2. “Do you eat large quantities of carbohydrates?” 3. “Please tell me about what foods and beverages you have consumed for the past 24 hours.” 4. “Have you noticed your energy level has decreased with your recent weight gain? Correct Answer: 3 Rationale 1: “Are you eating more than you should?” The focused interview of the client’s nutritional concerns will include asking the client to recall intake for the past 24 hours. The 24-hour period will provide insight into the dietary intake of the client by providing a snapshot of food selections and eating patterns. It is important not to appear judgmental during the focused interview. Asking the client if she is eating large quantities of food is subjective, may be interpreted by the client in a negative manner and will likely not yield the needed information. Rationale 2: “Do you eat large quantities of carbohydrates?” Questioning the client about carbohydrate directly is not the best tactic. The client may not be clear about which foods are sources of carbohydrates. Better information about the dietary intake can be obtained with a dietary recall. Rationale 3: “Please tell me about what foods and beverages you have consumed for the past 24 hours.” The focused interview of the client’s nutritional concerns will include asking the client to recall intake for the past 24 hours. The 24-hour period will provide insight into the dietary intake of the client by providing a snapshot of food selections and eating patterns. Rationale 4: “Have you noticed your energy level has decreased with your recent weight gain?” Energy levels may change with weight gain. The purpose of the focused interview at this point to so obtain information to guide the physical assessment in relation to nutrition and weight gain.

Global Rationale: The focused interview of the client’s nutritional concerns will include asking the client to recall intake for the past 24 hours. The 24-hour period will provide insight into the dietary intake of the client by providing a snapshot of food selections and eating patterns. It is important not to appear judgmental during the focused interview. Asking the client if she is eating large quantities of food is subjective, may be interpreted by the client in a negative manner and will likely not yield the needed information. Questioning the client about carbohydrate directly is not the best tactic. The client may not be clear about which foods are sources of carbohydrates. Better information about the dietary intake can be obtained with a dietary recall. Energy levels may change with weight gain. The purpose of the focused interview at this point is to obtain information to guide the physical assessment in relation to nutrition and weight gain. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.7: Develop questions to be used when completing a focused interview.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 10 Question 1 Type: MCMA 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? Standard Text: Select all that apply. 1. “As the nurse, I will mainly focus on the course of the client’s illness.” 2. “The client’s health history can be gathered during the initial interview.” 3. “I realize that the client is sick, but I also need to perform a wellness assessment.” 4. “The healthcare provider’s and nurse’s assessments should be almost identical with the same focus.” 5. “The nurse typically has a more holistic point of view regarding the client’s health.” Correct Answer: 1,4 Rationale 1: “As the nurse, I will mainly focus on the course of the client’s illness.” The healthcare provider will typically focus on the client’s illness, while the nurse will focus on the client. Rationale 2: “The client’s health history can be gathered during the initial interview.” The nurse can gather the health history during the initial interview. Rationale 3: “I realize that the client is sick, but I also need to perform a wellness assessment.” The nurse should perform a wellness assessment as part of the health history. Rationale 4: “The healthcare provider’s and nurse’s assessments should be almost identical with the same focus.” The healthcare provider’s focus and the nurse’s focus regarding the client’s health differ significantly. The nurse’s health history may produce information about a medical diagnosis, but the focus is on the client’s response to the health concern as a whole person. The healthcare provider focuses on specific body systems or body parts of the client. Rationale 5: “The nurse typically has a more holistic point of view regarding the client’s health.” The nurse does typically have a more holistic view of the client when compared to the healthcare provider’s point of view. Global Rationale: The healthcare provider will typically focus on the client’s illness, while the nurse will focus on the client. The healthcare provider’s focus and the nurse’s focus regarding the client’s health differ significantly. The nurse’s health history may produce information about a medical diagnosis, but the focus is on the client’s response to the health concern as a whole person. The healthcare provider focuses on specific body systems or body parts of the client. The nurse can gather the health history during the initial interview. The nurse should perform a wellness assessment as part of the health history. The nurse does typically have a more holistic view of the client when compared to the healthcare provider’s point of view.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.1: Discuss the purpose of the nursing health history. Question 2 Type: MCMA 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? Standard Text: Select all that apply. 1. “My mom was diagnosed with glaucoma when she was 60 years old.” 2. “I pay attention to the foods that I eat, because I want my body to stay well.” 3. “I think I do a good job of managing stress with yoga every day and running three times a week.” 4. “My husband and I have 3 couples that we would classify as our very good friends.” 5. “Sometimes, my eyes feel very tired and sort of ache.” Correct Answer: 2,3,4 Rationale 1: “My mom was diagnosed with glaucoma when she was 60 years old.” The nurse should ask about the client’s family history at some point during the health history but not during the wellness assessment. Rationale 2: “I pay attention to the foods that I eat, because I want my body to stay well.” The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how well the client is nourishing the body during the wellness assessment. Rationale 3: “I think I do a good job of managing stress with yoga every day and running three times a week.” The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how well the client is managing stress during the wellness assessment. Rationale 4: “My husband and I have 3 couples that we would classify as our very good friends.” The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how well the client is interacting socially during the wellness assessment. Rationale 5: “Sometimes, my eyes feel very tired and sort of ache.” The nurse should ask about the client’s symptoms related to the condition but not during the wellness assessment.

Global Rationale: The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how the client is nourishing the body, managing stress, and interacting socially. The client was diagnosed with glaucoma. Information about the client’s eyes may be gathered as the nurse focuses on the client’s health concerns or illness. The nurse should ask about the client’s family history at some point during the health history but not during the wellness assessment. The nurse should ask about the client’s symptoms related to the condition but not during the wellness assessment. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.1: Discuss the purpose of the nursing health history. Question 3 Type: MCMA While interviewing the client during the focused interview, the client begins to cry softly. Which of the following interventions by the nurse are appropriate? Standard Text: Select all that apply. 1. The nurse states, “It’s all right, I think we’re done with the interview.” 2. The nurse places the tissues within arm’s reach of the client. 3. The nurse remains quiet until the nurse feels that the client is prepared to proceed with the interview. 4. 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.” 5. The nurse states, “I can see you are upset. It’s all right to cry.” Correct Answer: 2,3,5 Rationale 1: The nurse states, “It’s all right, I think we’re done with the interview.” It is not appropriate to conclude the interview. There may be something that can help the nurse create a better care plan for the client if the nurse continues with this line of questioning. Rationale 2: The nurse places the tissues within arm’s reach of the client. When the client begins to cry or exhibits cues that the client may feel like crying, the nurse should place tissues within close proximity to the client. Rationale 3: The nurse remains quiet until the nurse feels that the client is prepared to proceed with the interview. It is appropriate for the nurse to remain quiet while the client cries. Rationale 4: 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.” It is appropriate for the nurse to give the client permission to cry. Some people need the assurance that it is okay to cry and feel sad.

Rationale 5: The nurse states, “I can see you are upset. It’s all right to cry.” The nurse should not hurry the interview along or not provide time for the client to display emotion. Global Rationale: When the client begins to cry or exhibits cues that the client may feel like crying, the nurse should place tissues within close proximity to the client. It is appropriate for the nurse to remain quiet while the client cries. It is appropriate for the nurse to give the client permission to cry. Some people need the assurance that it is okay to cry and feel sad. It is not appropriate to conclude the interview. There may be something that can help the nurse create a better care plan for the client if the nurse continues with this line of questioning. The nurse should not hurry the interview along or not provide time for the client to display emotion. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history. Question 4 Type: MCMA The nurse recently gave birth to a stillborn infant. During the preinteraction stage, the nurse learns that the client has had 5 elective abortions performed while she was in high school and college. Which of the following nursing actions are appropriate to help the nurse prepare emotionally for the initial interview with this client? Standard Text: Select all that apply. 1. The nurse speaks with one of her nursing peers and sets up a time to role-play the interview. 2. The nurse writes in her journal regarding her fears about meeting with the client. 3. The nurse makes an appointment to meet with her counselor prior to the interview. 4. The nurse should remain very quiet during the interview so that the initial interview will only last for a brief time. 5. The nurse creates a list of her own goals to accomplish during the interview with this client. Correct Answer: 1,2,3,5 Rationale 1: The nurse speaks with one of her nursing peers and sets up a time to role-play the interview. The nurse should speak with one of her nursing peers to role-play how the interview may proceed. Rationale 2: The nurse writes in her journal regarding her fears about meeting with the client. The nurse can write in a journal about some of her fears regarding the upcoming meeting with the client. Rationale 3: The nurse makes an appointment to meet with her counselor prior to the interview. The nurse can make an appointment to speak with her counselor about her feelings prior to the interview.

Rationale 4: The nurse should remain very quiet during the interview so that the initial interview will only last for a brief time. The nurse will not be able to elicit an adequate amount of information from the client if she is focusing only on being quiet during the interview. Rationale 5: The nurse creates a list of her own goals to accomplish during the interview with this client. The nurse can create a list of goals to accomplish during the interview. Global Rationale: The nurse should speak with one of her nursing peers to role-play how the interview may proceed. The nurse can write in a journal about some of her fears regarding the upcoming meeting with the client. The nurse can make an appointment to speak with her counselor about her feelings prior to the interview. The nurse can create a list of goals to accomplish during the interview. The nurse will not be able to elicit an adequate amount of information if she is focusing only on being quiet during the interview. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history. Question 5 Type: MCMA The student nurse and the experienced nurse are meeting with an elderly Vietnamese client who is unable to speak English. Which of the following actions indicate that the student nurse requires further education? Standard Text: Select all that apply. 1. The student nurse looks intently at the translator during the interview. 2. The student nurse is sitting directly beside the client and both of them are facing the translator. 3. The student nurse asks one question at a time. 4. The student nurse has requested that the client bring his daughter to the interview to translate for him. 5. The student nurse states, “Please tell him to void in this specimen container and to use a clean-catch technique when acquiring the urine.” Correct Answer: 1,2,4,5 Rationale 1: The student nurse looks intently at the translator during the interview. The student nurse should look at the client during the interview, not at the translator. Rationale 2: The student nurse is sitting directly beside the client and both of them are facing the translator. The student nurse should across from the client. The translator should sit next to the client.

Rationale 3: The student nurse asks one question at a time. The student nurse should ask one question at a time. Rationale 4: The student nurse has requested that the client bring his daughter to the interview to translate for him. The student nurse should not request that the client use his daughter as the translator. The student nurse should use language assistive services that health care agencies must provide at all points of contact, during all hours of operation. Rationale 5: The student nurse states, “Please tell him to void in this specimen container and to use a cleancatch technique when acquiring the urine.” The student nurse should avoid using any medical jargon. This may be difficult for the translator to understand and translate well. Global Rationale: The student nurse should look at the client during the interview, not at the translator. The student nurse should sit across from the client. The translator should sit next to the client. The student nurse should not request that the client use his daughter as the translator. The student nurse should use language assistive services that health care agencies must provide at all points of contact, during all hours of operation. The student nurse should avoid using any medical jargon. This may be difficult for the translator to understand and translate well. The student nurse should ask one question at a time. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history. Question 6 Type: MCSA 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? 1. Focusing 2. Attending 3. Paraphrasing 4. Summarizing Correct Answer: 1 Rationale 1: Focusing is used to help the client zero in on a subject or get in touch with feelings. Rationale 2: Attending is when the nurse gives the client undivided attention.

Rationale 3: Paraphrasing or clarifying is when the nurse restates the client’s basic message to test whether it was understood. Rationale 4: Summarizing is when the nurse ties together the various messages that the client has communicated throughout the interview. Global Rationale: Focusing is used to help the client zero in on a subject or get in touch with feelings. Attending is when the nurse gives the client undivided attention. Paraphrasing or clarifying is when the nurse restates the client’s basic message to test whether it was understood. Summarizing is when the nurse ties together the various messages that the client has communicated throughout the interview. Cognitive Level: Understanding Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history. Question 7 Type: MCSA 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. Listening 2. Attending 3. Questioning 4. Paraphrasing Correct Answer: 4 Rationale 1: Listening is paying undivided attention to what the client says and does. Rationale 2: Giving full attention to verbal and nonverbal messages is called attending. Body language may be as much as 93% of the message a client sends. Rationale 3: Questioning is a very direct way of speaking with clients to obtain subjective data for decision making and planning care. Questioning techniques include closed and open-ended questions. Rationale 4: Communication skills include checking to make sure that the nurse has understood the client accurately by paraphrasing. Paraphrasing, or clarification, means that the nurse restates the client’s basic message back to the client to ensure that the nurse understood the client’s message correctly.

Global Rationale: Communication skills include checking to make sure that the nurse has understood the client accurately by paraphrasing. Paraphrasing, or clarification, means that the nurse restates the client’s basic message back to the client to ensure that the nurse understood the client’s message correctly. Listening is paying undivided attention to what the client says and does. Giving full attention to verbal and nonverbal messages is called attending. Body language may be as much as 93% of the message a client sends. Questioning is a very direct way of speaking with clients to obtain subjective data for decision making and planning care. Questioning techniques include closed and open-ended questions. Cognitive Level: Understanding Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history. Question 8 Type: MCSA The nurse is interviewing the client. Which of the following techniques should the nurse use to decode the client’s messages? 1. Listen actively and attentively. 2. Develop and transmit an idea. 3. Use words to convey the message. 4. Use body language to convey the message. Correct Answer: 1 Rationale 1: Decoding a message makes communication successful and may break down if the nurse fails to listen attentively and actively. Rationale 2: Developing and transmitting an idea is how communication takes place. Rationale 3: Choosing words to convey a message is the definition of encoding. Rationale 4: Displaying body language to convey a message is the definition of encoding. Global Rationale: Decoding a message makes communication successful and may break down if the nurse fails to listen attentively and actively. Developing and transmitting an idea is how communication takes place. Choosing words and symbols to convey a message is the definition of encoding. Displaying body language to convey a message is the definition of encoding. Cognitive Level: Remembering Client Need: Psychosocial Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history. Question 9 Type: MCSA A client tells the nurse about two abortions she had while in college. The nurse responds, “What did you major in while you were in college?” This response is evidence of which type of barrier to communication? 1. Changing the subject 2. False reassurance 3. Cross-examination 4. Use of technical terms Correct Answer: 1 Rationale 1: This is an example of changing the subject. This nurse is changing the subject, which shows insensitivity to the client’s thoughts and feelings. This happens when the nurse is not at ease with the client’s comments and is unable to deal with the content. Rationale 2: False assurance occurs when the nurse assures the client of a positive outcome when there is no basis for believing in it. Rationale 3: Cross-examination is when questions are repeatedly directed to a client, causing the client to feel threatened. Rationale 4: Use of technical terms is when the nurse uses terms that are specific to the medical field. Global Rationale: This is an example of changing the subject. This nurse is changing the subject, which shows insensitivity to the client’s thoughts and feelings. This happens when the nurse is not at ease with the client’s comments and is unable to deal with the content. False assurance occurs when the nurse assures the client of a positive outcome when there is no basis for believing in it. Cross-examination is when questions are repeatedly directed to a client causing the client to feel threatened. Use of technical terms is when the nurse uses terms that are specific to the medical field. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.3: Identify barriers to effective nurse-client communication Question 10 Type: MCSA

The nurse is interviewing a client who is in acute pain. Which of the following actions by the nurse must be performed first? 1. Interview the family for the information. 2. Attempt to reduce the pain and complete the interview later. 3. Proceed very quickly with the interview. 4. Document why the interview could not be completed. Correct Answer: 2 Rationale 1: Although secondary sources (family members, the medical record, and other members of the healthcare team) can be used to gather data, the client provides the primary information and should be the first choice for data assessment when possible. Rationale 2: The ability to participate in an interview is diminished when the client is experiencing unrelieved or acute pain. The nurse must focus on measures to help relieve pain, and then gather in-depth information at another time. Rationale 3: The client will not be able to concentrate and provide as in-depth information as possible if experiencing pain; regardless of how fast or slow the process takes. Rationale 4: Pain reduction is the primary goal in this situation, as the interview must be completed in order to obtain necessary data. Global Rationale: The ability to participate in an interview is diminished when the client is experiencing unrelieved or acute pain. The nurse must focus on measures to help relieve pain, and then gather in-depth information at another time. Although secondary sources (family members, the medical record, and other members of the healthcare team) can be used to gather data, the client provides the primary information and should be the first choice for data assessment when possible. The client will not be able to concentrate and provide as in-depth information as possible if experiencing pain; regardless of how fast or slow the process takes. Pain reduction is the primary goal in this situation, as the interview must be completed in order to obtain necessary data. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.3: Identify barriers to effective nurse-client communication. Question 11 Type: MCSA The nurse is admitting a young client of Cuban descent to the hospital. The nurse responds in a culturally sensitive manner by choosing which of the following actions?

1. Allowing all family members to be present during the admission 2. Ensuring that the father of the young client is provided with adequate amounts of information regarding the young client’s care 3. Requesting that all family members wait in the waiting room 4. Ensuring that the mother of the young client is provided with adequate amounts of information regarding the young client’s care Correct Answer: 2 Rationale 1: The head of the Cuban household is the male. The client’s father should be recognized as the decision maker in this family. Rationale 2: The head of the Cuban household is the male. The client’s father will most likely make decisions regarding the young client’s care. Rationale 3: The head of the Cuban household is the male. The client’s father should be recognized as the decision maker in this family. Rationale 4: Native American groups look to mothers and grandmothers to make healthcare decisions. In Filipino households the authority in the family is shared, yet the decisions related to health care are made mostly by the women. The head of the Cuban household is the male. The father should be included when providing care for the young client. Global Rationale: The head of the Cuban household is the male. The father should be provided with appropriate information regarding the young client’s care. The client’s father will most likely make decisions regarding the young client’s care. Native American groups look to mothers and grandmothers to make healthcare decisions. In Filipino households the authority in the family is shared, yet the decisions related to health care are made mostly by the women. Determination of roles and relationships is important when planning health care and assisting the client to make healthcare decisions, and the nurse should be prepared to include recognized decision makers in the planning process. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.4: Describe the influence of culture on nurse-client interactions. Question 12 Type: SEQ The nurse is preparing to interview the client during the initial interview. Rank the following nursing statements in order of their most likely occurrence. Standard Text: Click and drag the options below to move them up or down.

Choice 1. “We’re almost done; do you have any questions for me?” Choice 2. “May I call you Anne?” Choice 3. “When you said you had been having trouble with your belly, what did you mean?” Choice 4. “So, can you tell me about what’s been going on with your health?” Correct Answer: 2,4,3,1 Rationale 1: The nurse should then close the interview by allowing the client to ask questions. Rationale 2: The nurse should first greet the client and ask if it is all right to call the client by her first name. Rationale 3: The nurse should ask questions to clarify information given by the client during the interview. Rationale 4: The nurse should initially ask generalized open-ended questions about the client’s health status. Global Rationale: The nurse should greet the client and ask if it is all right to call the client by her first name. The nurse should initially generalized open-ended questions about the client’s health status. The nurse should ask questions to clarify information given by the client during the interview. The nurse should then close the interview by allowing the client to ask questions. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.4: Describe the influence of culture on nurse-client interactions. Question 13 Type: MCSA While conducting the client’s health history, the nurse makes little eye contact with the client and focuses intently upon the computer while documenting the client’s information. The nurse faces the computer with legs crossed. Of the following types of nursing behaviors, which is most appropriate way to describe this situation? 1. A lack of empathy 2. A lack of genuineness 3. A lack of concreteness 4. A lack of positive regard Correct Answer: 2 Rationale 1: Empathy is the capacity to respond to another’s feelings and experiences as if they were your own. To a lesser extent, the nurse is displaying a lack of empathy by not communicating well with the client.

Rationale 2: Genuineness is the ability to present oneself honestly and spontaneously. This nurse is demonstrating a lack of genuineness. The nurse should use direct eye contact, facial expressions appropriate to the situation, and open body language. Facing the client, leaning forward during conversation, and sitting with arms and legs uncrossed are examples of open body language. Rationale 3: Concreteness means speaking to the client in specific terms instead of vague generalities. The nurse isn’t necessarily providing vague information for the client. Rationale 4: Positive regard is the ability to appreciate and respect another person’s worth and dignity with a nonjudgmental attitude. There is nothing in this scenario to suggest that the nurse is demonstrating a lack of positive regard. Global Rationale: Genuineness is the ability to present oneself honestly and spontaneously. This nurse is demonstrating a lack of genuineness. The nurse should use direct eye contact, facial expressions appropriate to the situation, and open body language. Facing the client, leaning forward during conversation, and sitting with arms and legs uncrossed are examples of open body language. Empathy is the capacity to respond to another’s feelings and experiences as if they were your own. To a lesser extent, the nurse is displaying a lack of empathy by not communicating well with the client. Concreteness means speaking to the client in specific terms instead of vague generalities. The nurse isn’t necessarily providing vague information for the client. Positive regard is the ability to appreciate and respect another person’s worth and dignity with a nonjudgmental attitude. There is nothing in this scenario to suggest that the nurse is demonstrating a lack of positive regard. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.5: Discuss the professional characteristics used in establishing a nurse-client relationship. Question 14 Type: MCMA The nurse is performing a focused interview with the client. Which of the following behaviors indicate that the client may be feeling anxious? Standard Text: Select all that apply. 1. While seated, the client begins to wiggle his foot back and forth quickly. 2. The client leans back in his chair and seems to move away from the nurse. 3. The client crosses his arms and becomes very quiet. 4. The client leans forward in the chair and uncrosses his legs. 5. The client seems to be distracted and is no longer making direct eye contact with the nurse. Correct Answer: 1,2,3,5

Rationale 1: While seated, the client begins to wiggle his foot back and forth quickly. If the client seems restless, this can indicate that the client is anxious. Rationale 2: The client leans back in his chair and seems to move away from the nurse. The client who leans back in his chair may be anxious and feels invaded by the nurse’s questions. Rationale 3: The client crosses his arms and becomes very quiet. The client who crosses his arms is expressing anxiety. Rationale 4: The client leans forward in the chair and uncrosses his legs. The client who leans forward in his chair and uncrosses his arms is not displaying anxiety. This behavior indicates that the client is preparing to “open up.” Rationale 5: The client seems to be distracted and is no longer making direct eye contact with the nurse. The client who seems distracted may be disengaging from the nurse’s interview due to anxiety. Global Rationale: If the client seems restless, this can indicate that the client is anxious. The client who leans back in his chair may be anxious and feels invaded by the nurse’s questions. The client who crosses his arms is expressing anxiety. The client who seems distracted may be disengaging from the nurse’s interview due to anxiety. The client who leans forward in his chair and uncrosses his arms is not displaying anxiety. This behavior indicates that the client may be preparing to “open up” with the nurse. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.6: Discuss the phases of the client interview. Question 15 Type: MCMA The nurse is preparing to interview the hospitalized client. Which of the following statements by the client’s nurse indicates that the interview should be postponed? Standard Text: Select all that apply. 1. “I can’t seem to get her pain under control this morning.” 2. “I just gave her morphine sulfate through her IV for pain about 20 minutes ago.” 3. “She was anxious earlier and received some lorazepam.” 4. “She’s been oriented to ‘self’ only since admission.” 5. “I gave her some ibuprofen about 1 hour ago.” Correct Answer: 1,2,3,4

Rationale 1: “I can’t seem to get her pain under control this morning.” The nurse should postpone the interview if the client is in pain. Rationale 2: “I just gave her morphine sulfate through her IV for pain about 20 minutes ago.” The interview should be postponed if the client received opioid pain medications because it may alter the ability for the client to adequately answer the nurse’s questions. Rationale 3: “She was anxious earlier and received some lorazepam.” The nurse should postpone the interview if the client was given lorazepam because it can sedate the client. Rationale 4: “She’s been oriented to ‘self’ only since admission.” The nurse should postpone the interview if the client is confused. Rationale 5: “I gave her some ibuprofen about 1 hour ago.” Ibuprofen will not impact the client’s ability to answer questions adequately, so the interview does not need to be postponed. Global Rationale: The nurse should postpone the interview if the client is in pain. The interview should be postponed if the client received opioid pain medications because it may alter the ability for the client to adequately answer the nurse’s questions. The nurse should postpone the interview if the client was given lorazepam because it can sedate the client. The nurse should postpone the interview if the client is confused. Ibuprofen will not impact the client’s ability to answer questions adequately, so the interview does not need to be postponed. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.6: Discuss the phases of the client interview. Question 16 Type: MCSA The nurse says to the client, “Before the healthcare provider comes in to see you, we will need to spend about 30 minutes talking about your current problem and any other health issues that might impact how you are feeling right now.” The nurse is participating in which phase of the health assessment interview? 1. Preinteraction 2. The initial interview 3. The focused interview 4. Closure of the interview Correct Answer: 2 Rationale 1: Preinteraction is when the nurse prepares to meet the client and reviews any available background information.

Rationale 2: The initial interview occurs when the nurse uses a period of time to talk with the client and document any information that would aid in care for the current health issue. Rationale 3: The focused interview occurs during the physical assessment, while providing treatment, and while providing care to the client. Rationale 4: Closure of the interview techniques can be used at the end of the initial interview or the focused interview. Global Rationale: This nurse is conducting the initial interview with this client. The health assessment interview has three phases. Preinteraction is when the nurse prepares to meet the client and reviews any available background information. The initial interview occurs when the nurse uses a period of time to talk with the client and document any information that would aid in care for the current health issue. The focused interview occurs during the physical assessment, while providing treatment, and while providing care to the client. Closure of the interview techniques can be used at the end of the initial interview or the focused interview. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.6: Discuss the phases of the client interview Question 17 Type: MCSA During the preinteraction stage, the nurse is preparing for the initial interview. Which of the following settings is the least appropriate setting for the initial interview? 1. The client has been admitted to the hospital with pneumonia. The nurse is preparing to interview the client in the client’s private hospital room. 2. The client lives at home. The nurse is preparing to interview the client in the client’s living room. 3. The client lives at home. The nurse is preparing to interview the client at a small coffee shop not far from the client’s home. 4. The client lives at home. The nurse is preparing to interview the client in the client’s backyard. Correct Answer: 3 Rationale 1: It is appropriate to interview the client in the client’s private hospital room. Rationale 2: When the client lives at home, it is appropriate to interview the client in his living room. Rationale 3: There should not be other people present during the interview because it may hamper the client’s ability to share an adequate amount of information with the nurse. Rationale 4: It is appropriate to interview the client in his own backyard.

Global Rationale: There should not be other people present during the interview because it may hamper the client’s ability to share an adequate amount of information with the nurse. A nearby coffee shop lacks privacy. It is appropriate to interview the client in the client’s private hospital room. When the client lives at home, it is appropriate to interview the client in his living room. It is appropriate to interview the client in his own backyard. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.6: Discuss the phases of the client interview. Question 18 Type: MCSA The nurse is gathering information regarding the client’s psychosocial history. Which of the following questions would be included in this assessment? 1. “How did your father die?” 2. “Have you had any major surgeries?” 3. “Have you noticed any change in your vision?” 4. “How long have you worked for your current employer?” Correct Answer: 4 Rationale 1: The nurse should gather information about the reasons for the father’s death when creating the client’s genogram and documenting the client’s family history. Rationale 2: Surgical history is a part of medical history. Rationale 3: Information about vision changes would be included in the review of body systems. Rationale 4: Elements of the psychosocial history within the health history include gathering information about the client’s occupational history, education, financial background, roles and relationships, family, social structure/emotional concerns, and self-concept. Global Rationale: Elements of the psychosocial history within the health history include gathering information about the client’s occupational history, education, financial background, roles and relationships, family, social structure/emotional concerns, and self-concept. The nurse should gather information about the reasons for the father’s death when creating the client’s genogram and documenting the client’s family history. Surgical history is a part of medical history. Assessment of vision would be included in the Review of Body Systems. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.7: Describe the components of the nursing health history. Question 19 Type: MCSA 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. Immunization records 3. Average amount of hours of sleep each night 4. Marital status Correct Answer: 2 Rationale 1: The client’s medication list is related to current history. The description of the client’s health patterns depicts a “lifestyle thread” that allows the nurse to see sets of related traits, habits, or acts that affect the client’s health, which then can be compared to standard health patterns, and identification of risk potential or subsequent nursing diagnoses can be determined. Rationale 2: Past history includes information about childhood diseases, immunizations, allergies, blood transfusions, major illnesses, hospitalizations, labor and deliveries, surgical procedures, mental, emotional or psychiatric health problems, and the use of alcohol, tobacco, and other substances. Rationale 3: The client’s sleep pattern is related to current health history. The description of the client’s health patterns depicts a “lifestyle thread” that allows the nurse to see sets of related traits, habits, or acts that affect the client’s health, which then can be compared to standard health patterns, and identification of risk potential or subsequent nursing diagnoses can be determined. Rationale 4: The client’s marital status is related to current history. The description of the client’s health patterns depicts a “lifestyle thread” that allows the nurse to see sets of related traits, habits, or acts that affect the client’s health, which then can be compared to standard health patterns, and identification of risk potential or subsequent nursing diagnoses can be determined. Global Rationale: Past history includes information about childhood diseases, immunizations, allergies, blood transfusions, major illnesses, hospitalizations, labor and deliveries, surgical procedures, mental, emotional or psychiatric health problems, and the use of alcohol, tobacco, and other substances. The medication list, sleep pattern, and marital status are related to current history. The description of the client’s health patterns depicts a “lifestyle thread” that allows the nurse to see sets of related traits, habits, or acts that affect the client’s health, which then can be compared to standard health patterns, and identification of risk potential or subsequent nursing diagnoses can be determined. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.7: Describe the components of the nursing health history. Question 20 Type: MCSA The nurse is completing a focused interview. Which of the following pieces of information would the nurse include during this interaction? 1. Identify new nursing diagnoses after clarifying previously obtained data. 2. Review information collected during client’s previous health screening activities. 3. Obtain biographic data about the client. 4. Review data from previous medical records. Correct Answer: 1 Rationale 1: The purpose of the focused interview is to clarify previously obtained assessment data, gather missing information about a specific health concern, update and identify new diagnostic cues as they occur, guide the direction of a physical assessment as it is being conducted, and identify or validate probable nursing diagnoses. Rationale 2: Reviewing information collected during the client’s previous health screening activities can be performed during the preinteraction stage. Rationale 3: Obtaining the client’s biographical information is included in the preinteraction stage. Rationale 4: Gathering data from previous medical records is included in the preinteraction stage. Global Rationale: The purpose of the focused interview is to clarify previously obtained assessment data, gather missing information about a specific health concern, update and identify new diagnostic cues as they occur, guide the direction of a physical assessment as it is being conducted, and identify or validate probable nursing diagnoses. Gathering data from previous medical records and biographic data about the client should be performed during the preinteraction stage. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.7: Describe the components of the nursing health history. Question 21 Type: MCMA The nurse is gathering client data from secondary sources. Which of the following sources would the nurse utilize to collect this data?

Standard Text: Select all that apply. 1. The client’s past medical records 2. The client 3. The history and physical 4. The client’s physical therapist 5. The client’s spouse Correct Answer: 1,3,4,5 Rationale 1: The client’s past medical records. The client’s past medical records is a secondary source of information. Rationale 2: The client. The client is considered the primary source of information. Rationale 3: The history and physical. The history and physical is a secondary source of information. Rationale 4: The client’s physical therapist. The client’s physical therapist is a secondary source of information. Rationale 5: The client’s spouse. The client’s spouse is a secondary source of information. Global Rationale: Secondary sources are used to augment and validate previously obtained data. The following are examples of secondary sources: medical records, the client’s history and physical, a physical therapist who has worked with the client, other healthcare personnel who have cared for the client, and the client’s spouse. The client is considered the primary source of information. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.7: Describe the components of the nursing health history. Question 22 Type: SEQ The nurse is documenting the following information that has been collected during the health history. Rank the following information in the order that it should be documented. Standard Text: Click and drag the options below to move them up or down. Choice 1. Diagnosed with renal insufficiency in 1997. Choice 2. Malignant melanoma (stage I) removed from one site in 1992.

Choice 3. Coronary artery bypass graft in July 2005. Choice 4. Diagnosed with hypertension in 2000. Correct Answer: 3,4,1,2 Rationale 1: The third item is the client’s diagnosis of renal insufficiency in 1997. Rationale 2: The fourth item is the client’s malignant melanoma that was removed from one site in 1992. Rationale 3: The first thing that should be documented is the coronary artery bypass graft in July 2005. Rationale 4: The second item is that the client was diagnosed with hypertension in 2000. Global Rationale: When recording data, the information should be written in descending order from present to past. The first thing that should be documented is the coronary artery bypass graft in July 2005. The second item is that the client was diagnosed with hypertension in 2000. The third item is the client’s diagnosis of renal insufficiency in 1997. The fourth item is the client’s malignant melanoma that was removed from one site in 1992. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.8: Obtain a health history. Question 23 Type: MCSA The nurse is interviewing an older African American client and determines that a teaching plan should be implemented. Based on the client’s race, which statement by the client may prompt the nurse to plan develop a teaching plan? 1. “My hands and feet are always cold.” 2. “I do not take calcium replacements.” 3. “My blood pressure is high most of the time.” 4. “I’m worried that my bones may be weak.” Correct Answer: 3 Rationale 1: Caucasians have a greater risk for peripheral arterial disease than African Americans. The client with cold hands and feet may have peripheral arterial disease. Rationale 2: Osteoporosis risk is greater for Asians and Caucasians than for African Americans. People with a high risk for developing osteoporosis should take calcium supplements.

Rationale 3: African Americans have a higher incidence of hypertension and hypertension-related kidney failure than Caucasians. Rationale 4: African Americans typically have higher bone densities than Caucasians and Asians and are less likely to experience problems to due to osteoporosis. Global Rationale: African Americans have a higher incidence of hypertension and hypertension-related kidney failure than Caucasians. Caucasians have a greater risk for peripheral arterial disease than African Americans. The client with cold hands and feet may have peripheral arterial disease. Osteoporosis risk is greater for Asians and Caucasians than for African Americans. African Americans typically have higher bone densities than Caucasians and Asians. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.8: Obtain a health history. Question 24 Type: MCSA During the course of a health history the nurse would like to review a client’s medications. Which of the following questions is most important to ask when gathering the medication history? 1. “Can you tell me how much the co-pay is for your medications?” 2. “Do you carry health insurance?” 3. “Can you tell me about any over-the-counter or prescription medications that you take?” 4. “Where do you store your medications in your home?” Correct Answer: 3 Rationale 1: When gathering the medication history, the nurse does not necessarily need to ask about the client’s “co-pay.” Rationale 2: When gathering the medication history, the nurse does not necessarily need to ask whether the client carries health insurance or not. Rationale 3: The nurse should gather information about medications that the client is currently using. The nurse should request information about all prescribed and over-the-counter medications that the client takes. The use of home remedies, folk remedies, herbs, teas, vitamins, dietary supplements, or other substances should also be listed. Rationale 4: The nurse does not necessarily need to ask where the client stores the medications within the home.

Global Rationale: The nurse should gather information about medications that the client is currently using. The nurse should request information about all prescribed and over-the-counter medications that the client takes. The use of home remedies, folk remedies, herbs, teas, vitamins, dietary supplements, or other substances should also be listed. The medication history does not include the client’s co-pay amount, if the client has a prescription benefit plan or health insurance, or where in the home the medications are stored. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.8: Obtain a health history. Question 25 Type: MCSA A client has been brought to the emergency room by a family member. The client is speaking incoherently. To obtain information about the client’s current health status, what should the nurse do? 1. Call the client’s healthcare provider. 2. Call the Medical Records department to obtain other records for the client. 3. Discuss the situation with the family member who brought the client to the hospital. 4. Conduct a thorough physical assessment and document the health history as “unable to obtain.” Correct Answer: 3 Rationale 1: Speaking with the client’s healthcare provider may be helpful when attempting to gather information about the client’s medical history. However, the family member may be able to provide more information regarding the client’s current health status. Rationale 2: Contacting the Medical Records department to ascertain this client’s old records will be helpful when gathering information about the client’s health history. Rationale 3: The primary and best source of information for the health assessment interview is the client. In some situations, the client might be unwilling or unable to provide information. The nurse should use another source of information if indicated. This client is incoherent and is accompanied by a family member. The nurse should talk with the family members. Rationale 4: The nurse should be able to gather information about the client’s current health status from the family member who is accompanying the client. The nurse does not need to document that this information is unavailable. Global Rationale: The primary and best source of information for the health assessment interview is the client. In some situations, the client might be unwilling or unable to provide information. The nurse should use another source of information if indicated. This client is incoherent and is accompanied by a family member. The nurse should talk with the family members. Phoning the healthcare provider or calling Medical Records for other

admission information might be appropriate at a later time. The nurse should not document the health history as “unable to obtain” since family members are available to provide this information. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.8: Obtain a health history. Question 26 Type: SEQ The nurse is interviewing a client who has been admitted to the hospital with severe abdominal pain. The nurse is assessing the client’s pain using the acronym OLDCART & ICE. Rank the following the statements by the nurse in order of the way they are normally assessed. Standard Text: Click and drag the options below to move them up or down. Choice 1. “How long have you had this pain?” Choice 2. “Would you please point to the location of your pain?” Choice 3. “How would you describe your pain? Is it sharp, dull, stabbing?” Choice 4. “Can you tell me when your pain first began?” Correct Answer: 3,2,4,1 Rationale 1: The third step is to determine the duration of the client’s pain. Rationale 2: The second step is to identify the location of the client’s pain. Rationale 3: The nurse would then assess the characteristics of the client’s pain. Rationale 4: Using OLDCART & ICE, the nurse would first assess onset of the client’s pain. Global Rationale: Using OLDCART & ICE, the nurse would first assess onset of the client’s pain. The second step is to identify the location of the client’s pain. The third step is to determine the duration of the client’s pain. The nurse would then assess the characteristics of the client’s pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.8: Obtain a health history. Question 27 Type: HOTSPOT

The nurse is creating a family genogram with the client’s family history information. Draw an arrow indicating that there are two individuals whom the client is unable to provide any information about for the nurse. [Please insert the genogram from the chapter 10 spec sheet, figure 10-7, only include the bottom portion, do not include any directions regarding how to read or make a genogram.]

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The nurse uses a diamond shape and places the number “2” within the diamond to indicate that there are two of her father’s siblings that she is unable to provide information about for the nurse. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.9: Develop a genogram. Question 28 Type: MCMA The nurse is developing a genogram. Which of the following pieces of information can be used to help identify the widowed female? Standard Text: Select all that apply. 1. A square is used to denote the female. 2. A circle is used to denote the male. 3. A horizontal line connects the circle and the square in the middle. 4. A line above the circle and square that is linked on the top of each shape.

5. The square has a diagonal line through the square from bottom left to upper right corner. Correct Answer: 3,5 Rationale 1: A square is used to denote the female. A square is used to denote a male. Rationale 2: A circle is used to denote the male. A circle is used to denote a female. Rationale 3: A horizontal line connects the circle and the square in the middle. When a horizontal line links the circle and the square in the middle, this indicates that the male and female are married. Rationale 4: A line above the circle and square that is linked on the top of each shape. A line above the circle and square that is linked on the top of each shape indicates the male and female are siblings. Rationale 5: The square has a diagonal line through the square from bottom left to upper right corner. A diagonal line through the square indicates the male has died. Global Rationale: When a horizontal line connects the circle and the square in the middle, this indicates that the male and female are married. A diagonal line through a square or circle indicates that the person has died. A diagonal line through the square indicates the male has died. A square is used to denote a male. A circle is used to denote a female. A line above the circle and square that is linked on the top of each shape indicates the male and female are siblings. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.9: Develop a genogram. Question 29 Type: MCSA 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. Family genogram 2. Health practices 3. Past medical history 4. Present health/illness Correct Answer: 1 Rationale 1: A genogram is a representation of family relationships and medical history and is the most effective method of recording large amounts of data gathered from a family’s health history.

Rationale 2: Health practices and beliefs about health and illness are important for the nurse to ascertain and are included in a general cultural assessment. Rationale 3: Past medical history includes any major illness, injuries, hospitalizations, allergies, immunizations, and childhood diseases. Rationale 4: Present health/illness includes information about all of the client’s current health-related issues, concerns, and problems as well as the reason for seeking care. Global Rationale: A genogram is a representation of family relationships and medical history and is the most effective method of recording large amounts of data gathered from a family’s health history. Health practices and beliefs about health and illness are important for the nurse to ascertain and are included in a general cultural assessment. Past medical history includes any major illness, injuries, hospitalizations, allergies, immunizations, and childhood diseases. Present health/illness includes information about all of the client’s current health-related issues, concerns, and problems as well as the reason for seeking care. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.9: Develop a genogram. Question 30 Type: HOTSPOT The nurse has created a genogram for the client using the client’s family history information. Draw an arrow pointing to the individual who is still alive, a male, and a widower. [Please insert the genogram from the chapter 10 spec sheet, figure 10-7, only include the bottom portion, do not include any directions regarding how to read or make a genogram.]

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : A square is used to denote a male. A circle is used to denote a female. Diagonal lines through the shape indicate that the individual has died. Married individuals are linked by a single horizontal line.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.9: Develop a genogram.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 11 Question 1 Type: HOTSPOT The nurse has performed a focused interview with the client and is preparing to perform a skin assessment while the student nurse observes. The student nurse asks, “Where exactly is the stratum basale located?” Identify the stratum basale in the following figure by placing an arrow pointing toward this area. [Please insert figure 11-1 from D’Amico 2nd edition: Skin structure, 3-dimensional view of skin….Remove all labels]

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. Global Rationale: Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.1: Identify the anatomy and physiology of the skin, hair, and nails. Question 2 Type: HOTSPOT The nurse is assessing the client’s nail. Identify the lunula by drawing an arrow pointing toward this area on the following figure.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix. Global Rationale: Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1: Identify the anatomy and physiology of the skin, hair, and nails. Question 3 Type: MCSA The nurse is conducting a focused interview on the client’s integumentary system and prepares to obtain data related to risk factors for the development of integumentary disorders. Which of the following questions by the nurse would be unexpected based on the specific data the nurse is attempting to gain during the interview? 1. “How much time do you spend outdoors?” 2. “How do you care for your skin?” 3. “Do you have any tattoos or body piercings?” 4. “Have you noticed any drainage from your skin?” Correct Answer: 4 Rationale 1: The nurse can ask the client about the amount of time that the client spends outside. Spending time outside in the sunshine is a risk factor for the development of skin disorders, such as squamous cell carcinoma.

Rationale 2: The nurse can ask the client about the way that the client cares for the skin. There may be something that the client is doing while caring for the skin that is a risk factor for the development of an integumentary disorder. Rationale 3: Tattoos and body piercings can increase the client’s risk for developing an integumentary disorder. Rationale 4: When the nurse asks the client about the presence of drainage from the skin, this question is directed at determining the presence of a clinical manifestation of an integumentary disorder. This question is not necessarily directed at gaining information about risk factors. Global Rationale: When the nurse asks the client about the presence of drainage from the skin, this question is directed at determining the presence of a clinical manifestation of an integumentary disorder. This question is not necessarily directed at gaining information about risk factors. The nurse can ask the client about the amount of time that the client spends outside. Spending time outside in the sunshine is a risk factor for the development of skin disorders, such as squamous cell carcinoma. The nurse can ask the client about the way that the client cares for the skin. There may be something that the client is doing while caring for the skin that is a risk factor for the development of an integumentary disorder. Tattoos and body piercings can increase the client’s risk for developing an integumentary disorder. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2: Develop questions to be used when completing the focused interview. Question 4 Type: MCSA The nurse is completing a focused interview to assess the skin, hair, and nails of a pregnant client. Which of the following questions would be most important for the nurse to include in the interview? 1. “Do you use any skin creams?” 2. “Do you try to avoid exposure to the sun?” 3. “Have you lost any hair during your pregnancy?” 4. “Have you had any nail changes?” Correct Answer: 1 Rationale 1: Topical medications may be absorbed through the skin and harm the fetus. Those that can cause birth defects include Retin A, antifungal agents, and minoxidil for hair growth. Other topical medications that can harm the baby include antibiotics, steroids, and medication for muscle pain. Rationale 2: Client should avoid sun exposure to prevent skin damage.

Rationale 3: Losing hair during pregnancy is not necessarily as important to assess as the client’s use of skin creams. Topical medications may be absorbed through the skin and harm the fetus. Rationale 4: Nail changes can be assessed, but it is most important to assess the client’s use of skin creams. Topical medications may be absorbed through the skin and harm the fetus. Global Rationale: Topical medications may be absorbed through the skin and harm the fetus. Those that can cause birth defects include Retin A, antifungal agents, and minoxidil for hair growth. Other topical medications that can harm the baby include antibiotics, steroids, and medication for muscle pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.2: Develop questions to be used when completing the focused interview. Question 5 Type: MCSA The nurse is preparing to assess the client’s skin, hair, and nails. Which of the following techniques will the nurse use initially during this assessment? 1. Percussion 2. Palpation 3. Auscultation 4. Inspection Correct Answer: 4 Rationale 1: There is no need to use percussion to assess the client’s skin, hair, and nails. Rationale 2: The nurse inspects then palpates during the assessment of the client’s skin, hair, and nails. Rationale 3: There is no need to use auscultation to assess the client’s skin, hair, and nails. Rationale 4: Inspection is the nurse’s first step when assessing the client’s skin, hair, and nails. Global Rationale: Physical assessment of the skin, hair, and nails is conducted by inspection and then with palpation. There is no need to use percussion to assess the client’s skin, hair, and nails. There is no need to use auscultation to assess the client’s skin, hair, and nails. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.3: Explain client preparation for assessment of the skin, hair, and nails. Question 6 Type: MCMA The client is visiting the healthcare provider’s office for a head-to-toe assessment. During the nurse’s assessment of the client’s skin, the nurse notes that the client is pale. Which of the following findings may be related to the client’s color? Standard Text: Select all that apply. 1. Client’s blood pressure is 96/62. 2. The client states, “I just smoked a cigarette before I came in the office.” 3. The client’s oxygen saturation level is 86% on room air. 4. The client states, “I have been diagnosed with osteoporosis.” 5. The client states, “It is snowing again outside with a wind chill factor of –11 degrees Fahrenheit.” Correct Answer: 1,2,3,5 Rationale 1: Client’s blood pressure is 96/62. Pallor may be seen in the client with hypotension. Rationale 2: The client states, “I just smoked a cigarette before I came in the office.” It can be produced by the sympathetic nervous stimulation that results in vasoconstriction due to smoking cigarettes. Rationale 3: The client’s oxygen saturation level is 86% on room air. The client with a decreased oxygen saturation level may exhibit pallor. Rationale 4: The client states, “I have been diagnosed with osteoporosis.” Pallor is not normally associated with osteoporosis. Rationale 5: The client states, “It is snowing again outside with a wind chill factor of –11 degrees Fahrenheit.” A cold environment can produce vasoconstriction and pallor. Global Rationale: Pallor may be seen in the client with hypotension. It can be produced by the sympathetic nervous stimulation that results in vasoconstriction due to smoking cigarettes. The client with a decreased oxygen saturation level may exhibit pallor. A cold environment can produce vasoconstriction and pallor. It is not normally associated with osteoporosis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 7 Type: MCSA The nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in color. The nurse would correctly document this finding as which of the following? 1. Uremia 2. Cyanosis 3. Jaundice 4. Carotenemia Correct Answer: 3 Rationale 1: Uremic skin is pale and yellow, but is associated with renal, and not liver, disease. The yellow tinge seen in the patient with uremic skin is very pale and does not affect conjunctivae or mucous membranes. Rationale 2: Cyanotic skin is bluish in color. Rationale 3: The nurse’s findings indicate jaundice, which is due to increased levels of bilirubin in the blood. Jaundice is visible in the sclerae, oral mucosa, junction of hard and soft palate, palms of the hands, and soles of the feet. Rationale 4: Carotenemic skin has a yellow-orange tinge. The yellow-orange tinge seen in the client with carotenemia is most visible in palms of the hands and soles of the feet. This client would not exhibit yellowing of sclerae or mucous membranes. Global Rationale: The nurse’s findings indicate jaundice, which is due to increased levels of bilirubin in the blood. Jaundice is visible in the sclerae, oral mucosa, junction of hard and soft palate, palms of the hands, and soles of the feet. Uremic skin is pale and yellow, but is associated with renal, and not liver, disease. The yellow tinge seen in the patient with uremic skin is very pale and does not affect conjunctivae or mucous membranes. Cyanotic skin is bluish in color. Carotenemic skin has a yellow-orange tinge. The yellow-orange tinge seen in the client with carotenemia is most visible in palms of the hands and soles of the feet. This client would not exhibit yellowing of sclerae or mucous membranes. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 8 Type: MCSA The nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.4 cm in size. The nurse would correctly document this finding as which of the following?

1. Vesicle 2. Macule 3. Papule 4. Tumor Correct Answer: 1 Rationale 1: The area described is a vesicle and may be caused by herpetic lesions, poison ivy, and small burn blisters. Rationale 2: A macule is a flat, nonpalpable change in skin color. Rationale 3: A papule is an elevated, solid, palpable mass. Rationale 4: Tumors are elevated, but solid, hard, or soft palpable and extend deeper into the dermis. Global Rationale: The area described is a vesicle and may be caused by herpetic lesions, poison ivy, and small burn blisters. A macule is a flat, nonpalpable change in skin color. A papule is an elevated, solid, palpable mass. Tumors are elevated, but solid, hard, or soft palpable and extend deeper into the dermis. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 9 Type: MCSA The nurse is caring for a client who has smoked for many years and documents that “clubbing is present.” Which of the following techniques is the best way for the nurse to determine the presence of clubbing? 1. Place two thumbs touching side-by-side. 2. Place two of the same fingers from each hand together. 3. Place two index fingers together tip-to-tip. 4. Place the hands out straight with the palm sides down. Correct Answer: 2 Rationale 1: Placing the thumbs together side-by-side is not an appropriate way to determine the presence of clubbing.

Rationale 2: To assess for clubbing, the nurse can use the Schamroth technique in which the nurse asks the client to bring the dorsal aspect of corresponding fingers together and if there is clubbing, a diamond is not formed and the distance increases at the fingertip. Rationale 3: Placing the index finger tip-to-tip is not an appropriate way to determine the presence of clubbing. Rationale 4: Placing the hands straight out with the palms facing downward is not an appropriate way to determine the presence of clubbing. Global Rationale: To assess for clubbing, the nurse can use the Schamroth technique in which the nurse asks the client to bring the dorsal aspect of corresponding fingers together and if there is clubbing, a diamond is not formed and the distance increases at the fingertip. Placing the thumbs together side-by-side is not an appropriate way to determine the presence of clubbing. Placing the index finger tip-to-tip is not an appropriate way to determine the presence of clubbing. Placing the hands straight out with the palms facing downward is not an appropriate way to determine the presence of clubbing. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 10 Type: MCSA The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse, “Why did this happen to me?” Which of the following statements is the nurse’s best response? 1. “Your diet is not nutritionally balanced.” 2. “You may have some hormone imbalances.” 3. “Usually, there is not a known cause for this condition.” 4. “You need to take vitamins.” Correct Answer: 2 Rationale 1: Hirsutism is not typically linked to nutrition. Rationale 2: Hirsutism is the occurrence of excess body hair in females on the face, chest, abdomen, arms, and legs, following the male pattern. It is typically due to endocrine or metabolic dysfunction, but may be idiopathic in nature. Rationale 3: Hirsutism is typically due to endocrine or metabolic dysfunction. Rationale 4: Clients with hirsutism do not need more vitamins, since hirsutism is often the result of endocrine or metabolic dysfunction.

Global Rationale: Hirsutism is the occurrence of excess body hair in females on the face, chest, abdomen, arms, and legs, following the male pattern. It is typically due to endocrine or metabolic dysfunction, but may be idiopathic in nature. Hirsutism is not typically linked to nutrition. Hirsutism is typically due to endocrine or metabolic dysfunction. Clients with hirsutism do not need more vitamins, since hirsutism is often the result of endocrine or metabolic dysfunction. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 11 Type: MCSA The nurse is inspecting the fingernails of a client with a diagnosis of polycythemia. Which of the following findings would be expected with this diagnosis? 1. Dark red nails 2. Horizontal white bands 3. Pale nail beds 4. Spoon-shaped nails Correct Answer: 1 Rationale 1: The client with polycythemia has nails that appear dark red due to a pathological increase in red blood cells. Rationale 2: Horizontal white bands in the nails are seen with the client who has been diagnosed with chronic hepatitis. Rationale 3: Pale nail beds are associated with anemia or peripheral circulatory disorders. Rationale 4: Spoon-shaped nails may be related to iron deficiency. Global Rationale: The client with polycythemia has nails that appear dark red due to a pathological increase in red blood cells. Horizontal white bands in the nails are seen with the client who has been diagnosed with chronic hepatitis. Pale nail beds are associated with anemia or peripheral circulatory disorders. Spoon-shaped nails may be related to iron deficiency. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 12 Type: MCSA The nurse is assessing the skin of a teenage male client and notes the presence of a musky odor. The client states that this is embarrassing for him and that he showers daily. Which of the following actions should the nurse take in this situation? 1. Reassure the teen that this is normal. 2. Notify the client’s healthcare provider. 3. Obtain a dietary referral. 4. Educate the client regarding the importance of increased water intake. Correct Answer: 1 Rationale 1: The apocrine glands are dormant until the onset of puberty when they become active and produce secretion of water, salts, fatty acids, and proteins. This secretion is released into hair follicles primarily in auxiliary and anogenital areas and when mixed with bacteria on skin surface produces a musky odor. This is a normal part of normal growth and development. Rationale 2: The teenage client’s healthcare provider does not need to be notified because this odor is associated with normal growth and development. Rationale 3: The nurse does not need to obtain a dietary referral because this odor is associated with normal growth and development. Rationale 4: Increasing fluid intake will not help prevent the occurrence of this odor. It is a normal part of normal growth and development. Global Rationale: The apocrine glands are dormant until the onset of puberty when they become active and produce secretion of water, salts, fatty acids, and proteins. This secretion is released into hair follicles primarily in auxiliary and anogenital areas and when mixed with bacteria on skin surface produces a musky odor. This is a normal part of normal growth and development. The teenage client’s healthcare provider does not need to be notified because this odor is associated with normal growth and development. The nurse does not need to obtain a dietary referral because this odor is associated with normal growth and development. Increasing fluid intake will not help prevent the occurrence of this odor. It is a normal part of normal growth and development. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 13 Type: MCSA

The nurse is caring for a client complaining of a painful, hot area located on the client’s leg. Erythema and edema are present in the localized area. Which of the following actions should the nurse perform next? 1. Palpate the area. 2. Place a heating pad on the area. 3. Notify the healthcare provider. 4. Place client on bed rest. Correct Answer: 3 Rationale 1: The nurse would not palpate the area. Reddened, swollen, localized, painful areas should not be palpated because these signs and symptoms indicate the presence of inflammation and possible infection. Disturbance may spread the infection into skin layers. Rationale 2: The nurse would not apply a heating pad to this site. Disturbance may spread the infection into skin layers. Rationale 3: Reddened, swollen, localized, painful areas should not be palpated because these signs and symptoms indicate the presence of inflammation and possible infection. Disturbance may spread the infection into skin layers. The healthcare provider should be notified. Rationale 4: The nurse would not necessarily place the client on bed rest. The healthcare provider should be notified. Global Rationale: Reddened, swollen, localized, painful areas should not be palpated because these signs and symptoms indicate the presence of inflammation and possible infection. Disturbance may spread the infection into skin layers. The healthcare provider should be notified. The nurse would not palpate the area. The nurse would not apply a heating pad to this site. The nurse would not necessarily place the client on bed rest. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 14 Type: MCSA The nurse is performing a skin assessment on a client and notes an oval-shaped, elevated, fluid-filled mass that is approximately 1.5 centimeter in size. The nurse would correctly document this finding as which of the following? 1. Vesicle 2. Bulla

3. Papule 4. Tumor Correct Answer: 2 Rationale 1: Vesicles are smaller than 0.5 centimeters but are also described as elevated, fluid-filled, round or oval-shaped, palpable mass with thin, translucent walls and circumscribed borders. Rationale 2: The area described is a bulla and may be caused by contact dermatitis, friction blisters, and large burn blisters. Rationale 3: A papule is an elevated, solid palpable mass with a circumscribed border. Papules are smaller than 0.5 centimeters. Rationale 4: Tumors are elevated, solid, hard, or soft palpable and extend deeper into the dermis. Global Rationale: The area described is a bulla and may be caused by contact dermatitis, friction blisters, and large burn blisters. Vesicles are smaller than 0.5 centimeters but are also described as elevated, fluid-filled, round or oval-shaped, palpable mass with thin, translucent walls and circumscribed borders. A papule is an elevated, solid palpable mass with a circumscribed border. Papules are smaller than 0.5 centimeters. Tumors are elevated, but solid, hard, or soft palpable and extend deeper into the dermis. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 15 Type: MCSA The adult client is visiting the outpatient clinic. The client states, “I have sores in my mouth and on my lips.” The nurse notes the presence of crusted lesions on the lips and inside the client’s mouth along the cheek. The client states that the lesions do not itch. These findings are most consistent with the development of which of the following conditions? 1. Chickenpox 2. Contact dermatitis 3. Herpes simplex 4. Psoriasis Correct Answer: 3

Rationale 1: Chickenpox is a mild infectious disease caused by the herpes zoster virus. It begins as groups of small, red, fluid-filled vesicles usually on the trunk, and progresses to the face, arms, and legs. Vesicles erupt over several days, forming pustules, then crusts. The condition may cause intense itching. It occurs mostly in children. Rationale 2: Contact dermatitis is inflammation of the skin due to an allergy to a substance that comes into contact with the skin, such as clothing, jewelry, plants, chemicals, or cosmetics. The location of the lesions may help identify the allergen. It may progress from redness to hives, vesicles, or scales, and is usually accompanied by intense itching. Rationale 3: The lesions described are typical for herpes simplex, which is a viral infection that produces such lesions. Rationale 4: Psoriasis is thickening of the skin in dry, silvery, scaly patches. It occurs with overproduction of skin cells resulting in buildup of cells faster than they can be shed. It may be triggered by emotional stress or generally poor health. It may be located on scalp, elbows and knees, lower back, and perianal area. Global Rationale: The lesions described are typical for herpes simplex, which is a viral infection that produces such lesions. Chickenpox is an infectious disease caused by the herpes zoster virus. It begins as groups of small, red, fluid-filled vesicles usually on the trunk, and progresses to the face, arms, and legs. Vesicles erupt over several days, forming pustules, then crusts. The condition may cause intense itching. It occurs mostly in children. Contact dermatitis is inflammation of the skin due to an allergy to a substance that comes into contact with the skin, such as clothing, jewelry, plants, chemicals, or cosmetics. The location of the lesions may help identify the allergen. It may progress from redness to hives, vesicles, or scales, and is usually accompanied by intense itching. Psoriasis is thickening of the skin in dry, silvery, scaly patches. It occurs with overproduction of skin cells resulting in buildup of cells faster than they can be shed. It may be triggered by emotional stress or generally poor health. It may be located on scalp, elbows and knees, lower back, and perianal area. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 16 Type: MCSA The nurse is assessing a client’s skin and notes that the color of the skin, nails, and the client’s mucous membranes are very light. Which of the following descriptions would the nurse use when documenting this finding? 1. Cyanosis 2. Pallor 3. Erythema 4. Jaundice

Correct Answer: 2 Rationale 1: Cyanotic skin is bluish in color. Rationale 2: Pallor is pale skin. It may occur with hypoxia, cold environment, stress, shock, hypotension, and anemia. Rationale 3: Erythema indicates that the skin is reddened. Rationale 4: Jaundice is used to describe yellowish skin. Global Rationale: Pallor, or paleness of the skin, may occur with hypoxia, cold environment, stress, shock, hypotension, and anemia. Cyanotic skin is blue in color; erythema is redness of the skin; and jaundiced skin has yellow undertones. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 17 Type: MCSA The client visits the outpatient clinic. During the assessment of the client’s skin, the nurse notes the presence of several abdominal lesions that appear in distinct clusters. The nurse would document these lesions in which of the following ways? 1. Grouped 2. Annular 3. Discrete 4. Confluent Correct Answer: 1 Rationale 1: The lesions described are grouped lesions because they appear in clusters. Rationale 2: Annular lesions are lesions with a circular shape. Rationale 3: Discrete lesions are lesions that are separate and discrete. Rationale 4: Confluent lesions run together. Global Rationale: The lesions described are grouped lesions because they appear in clusters. Annular lesions are lesions with a circular shape. Discrete lesions are separate. Confluent lesions run together.

Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 18 Type: MCMA The nurse has assessed the client’s skin. The nurse is preparing to document the appearance of herpetic lesions found over a client’s nose and mouth region. The healthcare provider diagnosed the client with herpes simplex. Which of the following are common words that are used to describe these types of lesions? Standard Text: Select all that apply. 1. Vesicular 2. Pustular 3. Pruritic 4. Ulcerated 5. Crusty Correct Answer: 1,2,5 Rationale 1: Vesicular. Herpes simplex lesions may be described as vesicular. Rationale 2: Pustular. Herpes simplex lesions may be described as pustular. Rationale 3: Pruritic. Herpes simplex lesions are not associated with pruritis. Rationale 4: Ulcerated. Herpes simplex lesions are not typically ulcerated. Rationale 5: Crusty. Herpes simplex lesions may be described as crusty. Global Rationale: Herpes simplex lesions progress from vesicles to pustules, and then crusts. They are not typically itchy (pruritic). They are not often described as being ulcerated. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 19

Type: MCSA The student nurse assessed the client’s skin. The student nurse documented “+1 edema right lower leg.” The experienced nurse expects to find which of the following based on the student nurse’s documentation? 1. The presence of slight pitting, no obvious distortion 2. Deep pitting, obvious distortion 3. Pitting is obvious, extremities are swollen 4. Moderate amount of edema Correct Answer: 1 Rationale 1: Edema, or accumulation of fluid in the body’s tissues, is recorded as +1, +2, +3, or +4. The designation +1 means the client has slight pitting in the right lower leg with no obvious distortion. Rationale 2: Deep pitting with obvious distortion may be documented as +4 edema. Rationale 3: Obvious pitting with swollen extremities may be described as +3 edema. Rationale 4: A moderate amount of edema may be described as +2 to +3 edema. Global Rationale: Edema, or accumulation of fluid in the body’s tissues, is recorded as +1, +2, +3, or +4. The designation +1 means the client has slight pitting in the right lower leg with no obvious distortion. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 20 Type: MCSA During the assessment of a client’s integumentary status the nurse notes “vitiligo present bilateral hands.” This documentation indicates which of the following information? 1. Nodules with ulcerations 2. Dark, asymmetrical colored patches 3. Grouped vesicles 4. Abnormal loss of melanin in patches Correct Answer: 4

Rationale 1: The term vitiligo does not indicate the presence of nodules with ulcerations. Rationale 2: The term vitiligo does not indicate the presence of dark, asymmetrical colored patches. Rationale 3: The term vitiligo does not indicate the presence of grouped vesicles. Rationale 4: Vitiligo is an abnormal loss of melanin in patches, typically occurring over the face, hands, or groin. Global Rationale: Vitiligo is an abnormal loss of melanin in patches, typically occurring over the face, hands, or groin. The term vitiligo does not indicate the presence of nodules with ulcerations. The term vitiligo does not indicate the presence of dark, asymmetrical colored patches. The term vitiligo does not indicate the presence of grouped vesicles. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment. Question 21 Type: MCSA The nurse is admitting a newly admitted client and notes skin vitiligo, which is highly visible even from a distance. The client asks the nurse to place a “No Visitors” sign on the door the patient’s room. The client states, “I hate the way my skin looks. Some people just stare at me.” Which of the following nursing diagnoses should be incorporated into the client’s plan of care? 1. Defensive coping 2. Risk for loneliness 3. Deficient knowledge 4. Disturbed body image Correct Answer: 4 Rationale 1: Defensive coping is not the best nursing diagnosis to apply to this client. This client has a disturbed body image. Rationale 2: The client does have a risk for loneliness but it is most likely due to the underlying disturbed body image. Rationale 3: There is nothing to indicate that the client has a deficient knowledge. This client is suffering from a disturbed body image due to the skin’s appearance. Rationale 4: This client has a visible skin disorder and is exhibiting signs that the client has a disturbed body image.

Global Rationale: A visible skin disorder may trigger psychosocial problems and a disturbed body image. This client has vitiligo, which is a skin condition. The client will exhibit patchy depigmented areas over some or all of the following body areas: face, neck, hands, feet, and body folds. A client with vitiligo may suffer a severe disturbance in body image. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 22 Type: MCSA The nurse received a phone call from a mother who was discharged with her newborn several days ago. The mother completed the infant care teaching prior to discharge. The nurse would determine that the teaching had been effective if the mother reported which of the following? 1. Tiny, white facial bumps 2. Yellow skin and mucous membrane color 3. Irregular red patches on the back of the neck 4. Dark spots on the sacral area Correct Answer: 2 Rationale 1: Milia are tiny, white facial papules due to sebum and will resolve within a few weeks of birth. Rationale 2: Yellowing of skin and mucous membranes in an infant who is 3–4 days old is temporary jaundice form of jaundice called physiological jaundice, but may require treatment with fluids and phototherapy. Rationale 3: Vascular markings are also called stork bites and may be located on the back of the neck. Rationale 4: Harmless skin markings requiring no intervention include gray, blue, or purple spots (Mongolian spots) on the buttocks or sacral area. Global Rationale: Yellowing of skin and mucous membranes in an infant who is 3–4 days old is temporary form of jaundice called physiological jaundice, but may require treatment with fluids and phototherapy. Milia are tiny, white facial papules due to sebum and will resolve within a few weeks of birth. Vascular markings are also called stork bites and may be located on the back of the neck. Harmless skin markings requiring no intervention include gray, blue, or purple spots (Mongolian spots) on the buttocks or sacral area. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 23 Type: MCSA The nurse is caring for a client with dark skin and needs to assess the skin for jaundice. Which of the following actions would be appropriate for the nurse in this situation? 1. Use a bright lamp and a magnifying glass. 2. Document "unable to assess" for skin changes. 3. Assess the skin the same way you would inspect a client with lighter skin. 4. Inspect the lips, oral mucosa, sclera, conjunctivae, and palms. Correct Answer: 4 Rationale 1: A bright light may assist the nurse, but the nurse should inspect the client’s lips, oral mucosa, sclera, conjunctivae, and palms when assessing for jaundice. Rationale 2: It is not appropriate to document that the nurse is unable to assess the client for jaundice. Rationale 3: The nurse will not find it as useful to assess the client with darker skin in the same way that the nurse would assess the client with lighter skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae. Rationale 4: Changes in skin color may be difficult to discover when assessing clients with dark skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae. Global Rationale: Changes in skin color may be difficult to discover when assessing clients with dark skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae. A bright light may assist the nurse, but the nurse should inspect the client’s lips, oral mucosa, sclera, conjunctivae, and palms when assessing for jaundice. It is not appropriate to document that the nurse is unable to assess the client for jaundice. The nurse will not find it as useful to assess the client with darker skin in the same way that the nurse would assess the client with lighter skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 24 Type: MCSA The nurse is assessing the skin of a newborn infant and notes a bright red, raised lesion on the lateral aspect of the thigh. The lesion is 4.5 centimeters in diameter. When light pressure is applied to the lesion, the site does not blanch. The mother expresses concern about the appearance of this site, and asks the nurse if it should be removed. Which of the following would be the best response for the nurse in this situation? 1. “Your pediatrician can make a surgical referral for you.” 2. “It really is not that noticeable.” 3. “You should be happy that your baby is healthy overall.” 4. “These types of lesions usually disappear by the time a child turns 10 years old.” Correct Answer: 4 Rationale 1: There is no reason for the nurse to speak with the pediatrician regarding a surgical referral. These types of lesions usually disappear by the time a child turns 10 years old. Rationale 2: The nurse should not indicate that the lesion is not that noticeable. The nurse should educate the mother about the lesion. Rationale 3: The nurse should not state that the mother should be happy with the overall health of the newborn. The mother is concerned about the appearance of the lesion and should be educated about the lesion and its normal course. Rationale 4: The lesion described is a hemangioma, which is a cluster of immature capillaries that can be found on any part of the body. These lesions usually disappear by age 10, and no intervention is needed. Global Rationale: The lesion described is a hemangioma, which is a cluster of immature capillaries that can be found on any part of the body. These lesions usually disappear by age 10, and no intervention is needed. The nurse should educate the mother about the lesion. The mother does not require comments suggesting she should ignore the lesion or be happy that the infant does not have more serious problems. The nurse should not state that the mother should be happy with the overall health of the newborn. The mother is concerned about the appearance of the lesion and should be educated about the lesion and its normal course. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 25 Type: MCSA

The nurse is performing a skin assessment on an African American client and notes an elevated, irregular band of jagged tissue on the client’s left arm. The client states, “I had a burn here a long time ago, but it seemed to keep on getting bigger.” The nurse would correctly document this finding in which of the following ways? 1. Ulcer 2. Keloid 3. Fissure 4. Scar Correct Answer: 2 Rationale 1: An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. This tissue is best described as a keloid. Rationale 2: This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent. Rationale 3: A fissure is a crack in the skin extending to the dermis. This tissue is best described as a keloid. Rationale 4: A scar is connective tissue left after healing, but is flat and usually linear. This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent. Global Rationale: This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent. An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. A fissure is a crack in the skin extending to the dermis. A scar is connective tissue left after healing, but is flat and usually linear. This tissue is best described as a keloid. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 26 Type: MCSA The nurse is caring for a client who had abdominal surgery several months ago. The client has verbalized concern that the scar from the surgery is purplish in color. Which of the following statements is the nurse’s best response? 1. “Having a scar is unavoidable.”

2. “The color is normal and will fade with time.” 3. “You can have plastic surgery to remove the scar later.” 4. “You should be glad your surgery was a success.” Correct Answer: 2 Rationale 1: The nurse should indicate that the scar will fade over time. The client is expressing concern regarding the appearance of the scar. Rationale 2: New scars may be red or purple in color and will fade to silvery or white with time. Rationale 3: The nurse should not suggest that the plastic surgery is an alternative to dealing with the scar. The nurse should indicate that the scar will fade over time. The client is expressing concern regarding the appearance of the scar. Rationale 4: The nurse should not express disapproval regarding the client’s concerns. The nurse should indicate that the scar will fade over time. The client is expressing concern regarding the appearance of the scar. Global Rationale: New scars may be red or purple in color and will fade to silvery or white with time. The nurse should not suggest plastic surgery, nor use statements that infer disapproval that the client is asking about the scar. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 27 Type: MCSA During the assessment of an elderly client’s skin, the nurse notes small areas of hyperpigmentation on the dorsal aspect of the client’s hands. The client states, “I’ve been getting more of these big freckles as I get older.” The nurse realizes this finding is due to: 1. Senile lentigines 2. Cherry angiomas 3. Cutaneous tags 4. Cutaneous horns Correct Answer: 1

Rationale 1: The nurse is describing “liver spots” or areas of hyperpigmentation over the backs of the client’s hands. Rationale 2: Cherry angiomas are small, bright red spots common in older adults. Rationale 3: Cutaneous tags may appear on the neck and upper chest. Rationale 4: Cutaneous horns may occur on any part of the face. Global Rationale: The nurse is describing “liver spots” or areas of hyperpigmentation over the backs of the client’s hands. Cherry angiomas are small, bright red spots common in older adults. Cutaneous tags may appear on the neck and upper chest. Cutaneous horns may occur on any part of the face. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 28 Type: MCSA The nurse is planning to assess an African American’s integumentary status. Which of the following statements by the client is most consistent with the presence of cyanosis? 1. “The whites of my eyes don’t look as white anymore; they have a little bit of a yellow cast to them.” 2. “My nails look a little bit bluish.” 3. “My nails are bright red.” 4. “My palms and the inside of my mouth look really pale.” Correct Answer: 2 Rationale 1: The client who states that the sclerae appear yellowish may have become jaundiced. Rationale 2: Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae in clients with darker skin color. Rationale 3: The client with bright red nails may be experiencing a sign of polycythemia. Rationale 4: The client with pale palms and mucous membranes may have developed pallor. Global Rationale: Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae in clients with darker skin color. The client who states that the sclerae appear yellowish may have become

jaundiced. The client with bright red nails may be experiencing a sign of polycythemia. The client with pale palms and mucous membranes may have developed pallor. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 29 Type: MCMA The nurse is preparing an educational program regarding the objectives listed in Healthy People 2020. Which of the following are specifically related to these objectives? Standard Text: Select all that apply. 1. African American females often require information regarding gentle hair and scalp care. 2. Infants have difficulty regulating their own body temperatures. 3. Older clients have increased sweat gland activity. 4. Clients with diabetes mellitus have an increased risk for skin breakdown. 5. Clients should monitor their moles for any changes, regardless of their age. Correct Answer: 1,2,4,5 Rationale 1: African American females often require information regarding gentle hair and scalp care. Nurses should provide African American women with information about the risks associated with chemical treatments, excessive combing, and pulling to braid fragile hair. Rationale 2: Infants have difficulty regulating their own body temperatures. Infants’ skin lacks the ability to contract. Therefore, they cannot shiver and do not perspire, limiting thermal regulation. Infants require clothing that is appropriate for the external temperature and environment. Rationale 3: Older clients have increased sweat gland activity Older clients are prone to reduced sweat gland activity, which can result in dry skin. Rationale 4: Clients with diabetes mellitus have an increased risk for skin breakdown. Clients with diabetes are at increased risk for problems with the skin and with healing of existing skin problems. Rationale 5: Clients should monitor their moles for any changes, regardless of their age. All clients should monitor moles for any changes in color, size, or texture. Global Rationale: Nurses should provide African American women with information about the risks associated with chemical treatments, excessive combing, and pulling to braid fragile hair. Infants’ skin lacks the ability to

contract. Therefore, they cannot shiver and do not perspire, limiting thermal regulation. Infants require clothing that is appropriate for the external temperature and environment. Clients with diabetes are at increased risk for problems with the skin and with healing of existing skin problems. All clients should monitor moles for any changes in color, size, or texture. Older clients are prone to reduced sweat gland activity, which leads to drier skin. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.6: Discuss the objectives related to overall health of the skin as presented in Healthy People 2020 documents. Question 30 Type: MCSA The nurse is performing an assessment of the client's skin when the nurse notes that the client has become pale and diaphoretic. The client’s vital signs have remained stable since the beginning of the examination: blood pressure 138/76, heart rate is 88 beats per minute, and respiratory rate is 18 breaths per minute. Which of the following actions should the nurse take first? 1. The nurse immediately raises the client’s head of bed. 2. The nurse asks the client, “Are you feeling anxious during this assessment?” 3. The nurse immediately notifies the client’s healthcare provider. 4. The nurse provides the client with ½ cup of orange juice. Correct Answer: 2 Rationale 1: The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client’s vital signs have remained stable. The nurse does not need to alter the position of the client’s head of bed. Rationale 2: Anxiety is commonly associated with the development of pallor and diaphoretic skin. This can often be resolved by determining the client’s level of anxiety and acknowledging the client’s anxiety. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client’s vital signs have remained stable. Rationale 3: The nurse does not need to notify the client’s healthcare provider. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client’s vital signs have remained stable. Rationale 4: The nurse does not need to provide the client with orange juice. Prior to providing the client with orange juice, the nurse would want to determine if the client was feeling anxious. The client’s serum glucose level should be assessed if hypoglycemia was suspected.

Global Rationale: Anxiety is commonly associated with the development of pallor and diaphoretic skin. This can often be resolved by determining the client’s level of anxiety and acknowledging the client’s anxiety. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client’s vital signs have remained stable. The nurse does not need to alter the position of the client’s head of bed. The nurse does not need to notify the client’s healthcare provider. The nurse does not need to provide the client with orange juice. Prior to providing the client with orange juice, the nurse would want to determine if the client was feeling anxious. The client’s serum glucose level should be assessed if hypoglycemia was suspected. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.7: Apply critical thinking in selected simulations related to physical assessment of the skin, hair, and nails.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 12 Question 1 Type: MCMA The nurse is assessing the client’s temporomandibular joint. The client complains of chronic pain at this site. Which of the following may have occurred as a result of this condition? Standard Text: Select all that apply. 1. The client has developed migraine headaches. 2. The client is unable to chew well and has lost weight since the pain began. 3. The client exhibits difficulty speaking clearly and enunciating words. 4. The client has developed hyperparathyroidism. 5. The client has developed torticollis. Correct Answer: 2,3,5 Rationale 1: The client has developed migraine headaches. Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. Clients with temporomandibular joint pain are more likely to develop cluster or tension headaches. Rationale 2: The client is unable to chew well and has lost weight since the pain began. Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. Rationale 3: The client exhibits difficulty speaking clearly and enunciating words. Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. Rationale 4: The client has developed hyperparathyroidism. Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. Pain at the site of temporomandibular joint is not associated with hyperparathyroidism. Rationale 5: The client has developed torticollis. Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. The client with temporomandibular joint pain can also develop painful muscle spasms in the neck called torticollis. Global Rationale: Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. Clients with temporomandibular joint pain are more likely to develop cluster or tension headaches than migraine headaches.

Pain at the site of temporomandibular joint is not associated with hyperparathyroidism. The client with temporomandibular joint pain can also develop painful muscle spasms in the neck called torticollis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck. Question 2 Type: HOTSPOT The nurse is assessing the client’s neck. Draw an “X” over the location of the axis.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis allows for movement of the head.

Global Rationale: Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck. Question 3 Type: MCSA The nurse is performing an assessment of the client’s head and neck. The client requests information about the assessment of her lymph nodes. Which of the following is the best response? 1. “Sometimes, enlarged lymph nodes indicate an infection.” 2. “All of your lymph nodes should be easily palpable.” 3. “The lymph system makes antibiotics to treat infection.” 4. “When one lymph node is identified as being enlarged, this is always an abnormal finding.” Correct Answer: 1 Rationale 1: The lymph nodes are part of the lymphatic system and provide the body with protection against infection. It is true that sometimes when the nurse is able to palpate enlarged lymph nodes this indicates that the client has developed an infection. Rationale 2: Lymph nodes should not be palpable. Rationale 3: The lymph system does not make antibiotics; it makes antibodies and lymphocytes to protect the client from infection. Rationale 4: It is not necessarily abnormal to be able to palpate one enlarged lymph node. Global Rationale: The head and neck are supplied by a large number of lymph nodes. The lymph nodes are part of the lymphatic system and provide the body with protection against infection. It is true that sometimes when the nurse is able to palpate enlarged lymph nodes this indicates that the client has developed an infection. Lymph nodes should not be palpable. The lymph system does not make antibiotics; it makes antibodies and lymphocytes to protect the client from infection. It is not necessarily abnormal to be able to palpate one enlarged lymph node. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck. Question 4

Type: MCSA The nurse is performing a physical examination on a 2-day-old infant and notes flattened areas on each side of the head. The mother expresses concern about the infant’s appearance. Which of the following responses would be appropriate for the nurse? 1. “The baby will likely need a neurologic evaluation.” 2. “The baby will need plastic surgery.” 3. “This is normal and will resolve in a few days.” 4. “What shape is your husband’s head?” Correct Answer: 3 Rationale 1: The infant will not require a neurologic evaluation because this is a normal finding. Rationale 2: The infant’s head will take on a more normal round shape in several days so plastic surgery is not required. Rationale 3: Infants born by vaginal delivery experience molding, which is shaping of the head as it passes through the vaginal canal. This will resolve in several days. Rationale 4: The shape of the infant’s head is normal after birth and is unrelated to the shape of the father’s head. Global Rationale: Infants born by vaginal delivery experience molding, which is shaping of the head as it passes through the vaginal canal. This will resolve in several days. The infant will not require a neurologic evaluation because this is a normal finding. The infant’s head will take on a more normal round shape in several days. The shape of the infant’s head is normal after birth and is unrelated to the shape of the father’s head. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck. Question 5 Type: MCSA The client has an enlarged lymph node in front of his right ear. In which of the following ways should the nurse accurately document this finding? 1. Right-sided occipital lymph node enlarged 2. Right-sided submaxillary lymph node enlarged 3. Right-sided deep cervical lymph node enlarged

4. Right-sided preauricular lymph node enlarged Correct Answer: 4 Rationale 1: The occipital lymph nodes are located at the base of the skull. Rationale 2: The submaxillary lymph nodes are located in the medial border of the mandible. Rationale 3: The deep cervical lymph nodes are located behind and inferior to the sternocleidomastoid muscle. Rationale 4: The preauricular lymph node is located in front of the ear. Global Rationale: The occipital lymph nodes are located at the base of the skull. The submaxillary lymph nodes are located in the medial border of the mandible. The deep cervical lymph nodes are located behind and inferior to the sternocleidomastoid muscle. The preauricular lymph node is located in front of the ear. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck. Question 6 Type: MCSA Which of the following findings is normal regarding assessment of the fontanels? 1. The nurse notes that the 2-week-old infant’s fontanels are slightly pulsing. 2. The 2-year-old child’s anterior fontanel remains unclosed. 3. The 1-month-old infant’s posterior fontanel has closed. 4. The 10-month-old infant’s anterior fontanel is shaped like a triangle. Correct Answer: 1 Rationale 1: The nurse may note that there are slight pulsations noted in the infant’s fontanels. Rationale 2: The anterior fontanel should be fully closed by 18 months of age. Rationale 3: The posterior fontanel should close at approximately 2 months of age. Rationale 4: The anterior fontanel should be shaped like a diamond. The posterior fontanel should be shaped like a triangle. Global Rationale: The nurse may note that there are slight pulsations noted in the infant’s fontanels. The anterior fontanel should be fully closed by 18 months of age. The posterior fontanel should close at approximately 2

months of age. The anterior fontanel should be shaped like a diamond. The posterior fontanel should be shaped like a triangle. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck. Question 7 Type: MCSA Which of the following information is true regarding the assessment of the thyroid or thyroid function in an infant or child? 1. To accurately assess thyroid function, the nurse should assess the child’s growth and development in comparison to others in the child’s age group. 2. The thyroid gland is easily palpable in an infant. 3. Assess the child for abnormal hair growth because this may indicate thyroid dysfunction. 4. Assess the child for melasma because this will indicate thyroid dysfunction. Correct Answer: 1 Rationale 1: The best way to assess thyroid function in an infant or child is to assess his growth and development in comparison to other people in his age group Rationale 2: The thyroid gland is difficult to palpate in an infant. Rationale 3: Long facial hair is usually seen in older women who are making less reproductive hormones. Rationale 4: Melasma is found in pregnant women. Melasma occurs when the pregnant female develops large, blotchy, pigmented areas on her face. Global Rationale: The best way to assess thyroid function in an infant or child is to assess his growth and development in comparison to other people in his age group. Laboratory tests can also help the clinician determine thyroid function. The thyroid gland is difficult to palpate in an infant. Long facial hair is usually seen in older women who are making less reproductive hormones. Melasma is found in pregnant women. Melasma occurs when the pregnant female develops large, blotchy, pigmented areas on her face. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 8 Type: MCSA The pregnant female has entered her third trimester. The client has developed hypertension and has been diagnosed with preeclampsia. Which of the following would the nurse also expect to find during the assessment of this client? 1. Dehydration 2. Complaints of increasing headaches 3. Decreased reproductive hormone levels 4. Lack of protein excretion in client’s urine Correct Answer: 2 Rationale 1: Preeclampsia is associated with fluid retention, not dehydration. Rationale 2: Preeclampsia is associated with hypertension, fluid retention, complaints of headaches, increased hormone levels, and an increase amount of urinary protein excretion. Rationale 3: Preeclampsia is associated with increased hormone levels. Rationale 4: Preeclampsia is associated with an increased amount of urinary protein excretion. Global Rationale: This pregnant client has developed preeclampsia. This condition occurs after 20 weeks gestation. It is associated with hypertension, fluid retention, complaints of headaches, increased hormone levels, and an increase amount of urinary protein excretion. Preeclampsia is important to identify because it can result in restricted blood flow to the placenta and may harm the developing fetus. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck. Question 9 Type: MCSA The client is preparing to examine the client’s head. Which of the following clients may prohibit the nurse from performing this portion of the exam? 1. Caucasian from the United States 2. African American 3. Mexican American

4. Native American Indian Correct Answer: 4 Rationale 1: Touching the head is not a cultural taboo for this group. Rationale 2: Touching the head is not a cultural taboo for this group. Rationale 3: Touching the head is not a cultural taboo for this group. Rationale 4: The cultural groups who may prohibit a thorough examination of their heads are Native Americans, people from Southeast Asia, and some Latino cultures. Global Rationale: Some cultural groups believe that the touching of another person’s head is inappropriate and this type of examination would be unwelcome. They believe that the soul or spirit resides within their heads. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck. Question 10 Type: MCMA The client is complaining of pain in his temporomandibular joint. During the nurse’s assessment of this client, which of the following pieces of information does the nurse expect to find? Standard Text: Select all that apply. 1. The client has been under a great deal of stress due to a recent divorce. 2. The client has developed hypothyroidism. 3. The client has lost tooth enamel due to nighttime teeth grinding. 4. The client has developed hypotension. 5. The client has developed severe tension headaches. Correct Answer: 1,3,5 Rationale 1: The client has been under a great deal of stress due to a recent divorce. Stress can produce unconscious jaw clenching that can result in temporomandibular joint pain. Rationale 2: The client has developed hypothyroidism. Temporomandibular joint pain is not associated with hypothyroidism. Perhaps, the client with hyperthyroidism may experience more stress related to sympathetic nervous system stimulation and this could possibly result in teeth grinding and temporomandibular joint pain.

Rationale 3: The client has lost tooth enamel due to nighttime teeth grinding. Some clients with temporomandibular joint pain grind their teeth at night and wear down their tooth enamel. Rationale 4: The client has developed hypotension. Temporomandibular joint pain is not associated with hypotension. The client with stress may develop hypertension and temporomandibular joint pain. Rationale 5: The client has developed severe tension headaches. Clients with temporomandibular joint pain are more prone to tension headaches. Global Rationale: Stress can produce unconscious jaw clenching that can result in temporomandibular joint pain. Some clients with temporomandibular joint pain grind their teeth at night and wear down their tooth enamel. Clients with temporomandibular joint pain are more prone to tension headaches. Temporomandibular joint pain is not associated with hypothyroidism. Perhaps, the client with hyperthyroidism may experience more stress related to sympathetic nervous system stimulation and this could possibly result in teeth grinding and temporomandibular joint pain. Temporomandibular joint pain is not associated with hypotension. The client with stress may develop hypertension and temporomandibular joint pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck. Question 11 Type: MCSA Which of the following countries have decreased their population’s risk of developing thyroid disease by adding iodine to salt? 1. India 2. United States 3. Australia 4. China Correct Answer: 2 Rationale 1: People who live in India and China have a higher risk of developing thyroid disease related to iodine deficiencies. Rationale 2: The use of iodized salt has reduced iodine defiencies and thyroid problems for people who live in the United States. Rationale 3: Australia, some areas in Eastern Europe, and South America have trouble with iodine deficiency due to their soil, which is typically poor in iodine.

Rationale 4: People who live in India and China have a higher risk of developing thyroid disease related to iodine deficiencies. Global Rationale: Thyroid problems are common in areas where iodine is limited. The use of iodized salt has reduced iodine defiencies and thyroid problems for people who live in the United States. People who live in India and China have a higher risk of developing thyroid disease related to iodine deficiencies. Australia, some areas in Eastern Europe, and South America have trouble with iodine deficiency due to their soil, which is typically poor in iodine. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck. Question 12 Type: MCSA During a focused interview of a client, the nurse learns about an open lesion on theclient’s head that hasn’t healed in several months. What might this indicate to the nurse? 1. The client may have a thyroid disease. 2. The client may have a malignancy. 3. The client may be pregnant. 4. The client may have meningitis. Correct Answer: 2 Rationale 1: This finding doesn’t necessarily indicate the client has a thyroid problem. Rationale 2: Wounds or lesions that do not heal, swellings, or masses should be assessed because this finding may indicate the client has a malignancy. Rationale 3: Pregnancy does not make the body less likely to heal. Rationale 4: This particular client does not exhibit symptoms of meningitis such as complaints of a stiff neck and headache. Global Rationale: Wounds or lesions that do not heal, swellings, or masses should be assessed because this finding may indicate the client has a malignancy. This finding doesn’t necessarily indicate the client has a thyroid problem. Pregnancy does not make the body less likely to heal. This particular client does not exhibit symptoms of meningitis such as complaints of a stiff neck and headache. Cognitive Level: Understanding Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.2: Develop questions to be used when completing the focused interview. Question 13 Type: MCMA A client complains of daily headaches. Which of the following would the nurse include in the focused interview? Standard Text: Select all that apply. 1. “Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst.” 2. “Tell me exactly where the pain is located.” 3. “Is there anything that relieves the pain, like resting or medication?” 4. “Is the pain sharp, dull, steady, or throbbing?” 5. “Have you had a recent cold or infection?” Correct Answer: 1,2,3,4,5 Rationale 1: “Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst.” The nurse should gather as much information about the client’s pain as possible. The nurse should gather information about the pain’s intensity. Rationale 2: “Tell me exactly where the pain is located.” The nurse should gather as much information about the client’s pain as possible. The nurse should gather information about the pain’s location. Rationale 3: “Is there anything that relieves the pain, like resting or medication?” The nurse should determine if there is anything that helps alleviate the client’s pain, such as resting, medication, or exercise. Rationale 4: “Is the pain sharp, dull, steady, or throbbing?” It is important to assess the character of the pain. Rationale 5: “Have you had a recent cold or infection?” Sometimes headaches can be associated with recent colds or infections. Global Rationale: The nurse should gather as much information about the client’s pain as possible. The nurse should gather information about the pain’s location, intensity, character, and location. The nurse should determine if there is anything that helps alleviate the client’s pain, such as resting, medication, or exercise. Sometimes headaches can be associated with recent colds or infections. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.2: Develop questions to be used when completing the focused interview.

Question 14 Type: MCSA The nurse finds the client’s thyroid gland is enlarged during the physical assessment. The client states that she has had a history of a goiter in the past. Which of the following questions is a priority to ask during the focused interview? 1. “Where do you purchase your medication?” 2. “What type of salt do you use in your diet?” 3. “Do you work around chemicals?” 4. “How long have you had this problem?” Correct Answer: 2 Rationale 1: Although this question is important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the client’s past history and present symptomatology. Rationale 2: Thyroid disease is common where iodine is limited and deficient amounts of iodine can cause a goiter to develop. Use of iodized salt in the U.S. has generally eliminated iodine deficiencies. Rationale 3: Although this question is important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the client’s past history and present symptomatology. Rationale 4: Although this question is important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the client’s past history and present symptomatology. Global Rationale: Thyroid disease is common where iodine is limited and deficient amounts of iodine can cause a goiter to develop. Use of iodized salt in the U.S. has generally eliminated iodine deficiencies. Although the other questions are important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the client’s past history and present symptomatology. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.2: Develop questions to be used when completing the focused interview. Question 15 Type: MCSA 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. Infection

2. Thyroid disease 3. Dehydration 4. Fetal Alcohol Syndrome Correct Answer: 3 Rationale 1: Infection would result in bulging fontanels. Rationale 2: Thyroid disease would not necessarily alter the state of the fontanels. Rationale 3: Sunken or depressed fontanels in an infant can indicate dehydration. Rationale 4: Fetal Alcohol Syndrome results in specific facial malformations. Global Rationale: Sunken or depressed fontanels in an infant can indicate dehydration. Infection would result in bulging fontanels. Thyroid disease would not necessarily alter the state of the fontanels. Fetal Alcohol Syndrome results in specific facial malformations. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.2: Develop questions to be used when completing the focused interview. Question 16 Type: MCSA The nurse is assessing the client’s head and neck. The nurse provides the client with a glass of water. Which of the following structures will the nurse most likely need to assess as the client drinks? 1. Temporomandibular joint 2. Lymph nodes 3. Temporal artery 4. Trachea Correct Answer: 4 Rationale 1: The temporomandibular joint should be inspected and palpated. Rationale 2: The lymph nodes are inspected and palpated. Rationale 3: The temporal artery can be inspected and palpated.

Rationale 4: The nurse will ask the client to drink from the glass of water when the nurse is ready to assess the hyoid bone, tracheal cartilage, and thyroid as the client swallows. Global Rationale: Physical assessment of the head and neck requires the use of inspection, palpation, and auscultation. The nurse will ask the client to drink from the glass of water when the nurse is ready to assess the hyoid bone, tracheal cartilage, and thyroid as the client swallows. The temporomandibular joint should be inspected and palpated. The lymph nodes are inspected and palpated. The temporal artery can be inspected and palpated. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3: Describe the techniques required for assessment of the head and neck. Question 17 Type: MCSA The nurse is assessing the client’s neck. Which of the following findings is abnormal? 1. The client’s carotid arteries are visibly pulsating. 2. The neck is symmetrical. 3. The tracheal cartilage does not move when the client swallows. 4. The thyroid has no palpable nodules. Correct Answer: 3 Rationale 1: It is normal to note that a client’s carotid arteries visibly pulse during inspection of the neck. Rationale 2: The neck should be smooth and symmetrical. Rationale 3: The tracheal cartilage should move when the client swallows. Rationale 4: The thyroid should be free of any nodules and this would be noted during palpation. Global Rationale: It is normal to note that a client’s carotid arteries visibly pulse during inspection of the neck. The neck should be smooth and symmetrical. The thyroid should be free of any nodules and this would be noted during palpation. The tracheal cartilage should move when the client swallows. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3: Describe the techniques required for assessment of the head and neck.

Question 18 Type: MCSA 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 III 2. Cranial nerve V 3. Cranial nerve VII 4. Cranial nerve VI Correct Answer: 2 Rationale 1: Cranial nerve III assists with controlling the movement of the eyes. Rationale 2: Cranial nerve V stimulates the movement needed for chewing, which is also known as mastication. Rationale 3: Cranial nerve VII is responsible for controlling the client’s facial movements. Rationale 4: Cranial nerve VI assists with controlling the movement of the eyes. Global Rationale: Cranial nerve III assists with controlling the movement of the eyes. Cranial nerve V stimulates the movement needed for chewing, which is also known as mastication. Cranial nerve VII is responsible for controlling the client’s facial movements. Cranial nerve VI assists with controlling the movement of the eyes. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 19 Type: MCSA The nurse is auscultating the temporal artery and hears a soft blowing sound. How would the nurse correctly document this finding? 1. Bruit 2. Murmur 3. Stenosis

4. Occlusion Correct Answer: 1 Rationale 1: A bruit can be heard through the bell of the stethoscope as a soft, blowing sound and is indicative of narrowing of the vessel. This is an abnormal sound. Rationale 2: The sound described is not a murmur, which is heard when auscultating the heart. Rationale 3: Stenosis is a medical diagnosis and the nurse should not document any conclusive diagnoses from assessment findings. Rationale 4: When a vessel is occluded, there is no associated sound because blood is not flowing through the vessel. Global Rationale: A bruit can be heard through the bell of the stethoscope as a soft, blowing sound and is indicative of narrowing of the vessel. This is an abnormal sound. The sound described is not a murmur, which is heard when auscultating the heart, and the nurse should not document any conclusive diagnoses from assessment findings. Stenosis is a medical diagnosis. When an artery is stenosed, it can create a bruit. When a vessel is occluded, there is no associated sound because blood is not flowing through the vessel. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 20 Type: MCSA The nurse is palpating an adult client’s neck and does not note any palpable lymph nodes. The nurse understands that this is: 1. probably due to an infection. 2. a normal finding in adults. 3. reason for referral to an ear, nose, and throat specialist. 4. cause to inspect for further malformations. Correct Answer: 2 Rationale 1: Lymph nodes of the head and neck are non-palpable in adults. If an infection were present, the lymph nodes of the surrounding area may be tender and possibly enlarged. Rationale 2: The lymph nodes that are located in the adult client’s neck should not be able to be palpated.

Rationale 3: There is no reason to refer the client to a specialist or to inspect the client for further malformations in the neck because it is normal to be unable to palpate lymph nodes. Rationale 4: There is no reason to refer the client to a specialist or to inspect the client for further malformations in the neck because it is normal to be unable to palpate lymph nodes. Global Rationale: Lymph nodes of the head and neck are nonpalpable in adults. If an infection were present, the lymph nodes of the surrounding area may be tender and possibly enlarged. The lymph nodes that are located in the adult client’s neck should not be able to be palpated. There is no reason to refer the client to a specialist or to inspect the client for further malformations in the neck because it is normal to be unable to palpate lymph nodes. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 21 Type: MCMA The nurse is examining a client’s neck. Which of the following would the nurse use as the correct method to palpate the trachea? Standard Text: Select all that apply. 1. Palpate while the client is swallowing. 2. Slide the thumb and index finger upward on each side of the trachea. 3. Palpate the midline of the neck to feel the cricoid cartilage. 4. Ask the client to open and close her mouth. 5. Stand behind the client and ask her to turn her head. Correct Answer: 1,2,3 Rationale 1: Palpate while the client is swallowing. The nurse should confirm that the hyoid bone and tracheal cartilages move up when the client swallows. Rationale 2: Slide the thumb and index finger upward on each side of the trachea. The nurse should use his thumb and index finger to identify the thyroid cartilage as he slides these fingers up the client’s neck. Rationale 3: Palpate the midline of the neck to feel the cricoid cartilage. The trachea should be midline. The C rings are also called cricoid cartilage.

Rationale 4: Ask the client to open and close her mouth. The client should be asked to open and close her mouth during inspected and palpation of the temporomandibular joint. Rationale 5: Stand behind the client and ask her to turn her head. The range of motion of the client’s neck can be partially assessed in this manner. Global Rationale: The nurse should use his thumb and index finger to identify the thyroid cartilage as he slides these fingers up the client’s neck. The nurse should confirm that the hyoid bone and tracheal cartilages move up when the client swallows. The trachea should be midline. The C rings are also called cricoid cartilage. The client should be asked to open and close her mouth during inspected and palpation of the temporomandibular joint. The range of motion of the client’s neck can be partially assessed by standing behind the client and asking her to turn her head. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 22 Type: HOTSPOT The nurse needs to palpate the submental lymph node on a client. Draw an arrow to the spot where the nurse would palpate.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The submental lymph node is just below the chin and should be palpated with one hand. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 23 Type: MCSA The nurse is planning care for a client with hypothyroidism. Which of the following would be the priority nursing diagnosis for this client? 1. Risk for constipation related to metabolic imbalance 2. Activity intolerance related to fatigue 3. Risk for injury related to confusion and lethargy 4. Altered nutrition, less than body requirements Correct Answer: 2 Rationale 1: While confusion, lethargy, and constipation are commonly associated with hypothyroidism, these are conditions that are not present according to the nursing diagnosis statement and therefore do not carry the same priority as those that are actually present. Rationale 2: Feeling tired, exhausted, and not having enough energy to perform even small tasks is a typical complaint from clients suffering from hypothyroidism.

Rationale 3: While confusion, lethargy, and constipation are commonly associated with hypothyroidism, these are conditions that are not present according to the nursing diagnosis statement and therefore do not carry the same priority as those that are actually present. Rationale 4: Typically, the client with hypothyroidism, though he may not have an appetite, may be gaining weight. Global Rationale: Feeling tired, exhausted, and not having enough energy to perform even small tasks is a typical complaint from clients suffering from hypothyroidism. While confusion, lethargy, and constipation are commonly associated with hypothyroidism, these are conditions that are not present according to the nursing diagnosis statement and therefore do not carry the same priority as those that are actually present. Typically, the client with hypothyroidism, though he may not have an appetite, may be gaining weight. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 24 Type: MCSA 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. “This will probably disappear on its own in several weeks.” 3. “The onset of Bell’s palsy is very slow and the effects can linger for several months.” 4. “Your cranial nerve VII is not functioning appropriately.” Correct Answer: 3 Rationale 1: Bell’s palsy is believed to occur as a result of viral infection. Rationale 2: The condition usually resolves spontaneously after several weeks. Rationale 3: The onset is sudden and there aren’t lingering effects after the condition resolves in several weeks after onset. Rationale 4: Cranial nerve VII is not functioning appropriately as a result of the viral infection. This results in the unilateral facial paralysis associated with the condition. Global Rationale: Bell’s palsy is believed to occur as a result of viral infection. The condition usually resolves spontaneously after several weeks. The onset is sudden and there aren’t lingering effects after the condition

resolves in several weeks after onset. Cranial nerve VII is not functioning appropriately as a result of the viral infection. This results in the unilateral facial paralysis associated with the condition. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 25 Type: MCSA The nurse is auscultating the thyroid gland and notes a bruit. Which of the following would the nurse associate with this finding? 1. Indicates stenosis of the thyroid artery. 2. Is a normal finding. 3. Indicates increased blood flow. 4. Occurs with hypothyroidism. Correct Answer: 3 Rationale 1: A bruit does not indicate stenosis, which is when blood flow is restricted through a blood vessel. Rationale 2: This is not a normal finding. Rationale 3: If the thyroid is enlarged, blood flows through the arteries at an accelerated rate, producing a soft, rushing sound and is detected with the bell of the stethoscope as a bruit. Rationale 4: Hypothyroidism can produce a smaller than normal thyroid gland and decreased blood flow. Global Rationale: If the thyroid is enlarged, blood flows through the arteries at an accelerated rate, producing a soft, rushing sound and is detected with the bell of the stethoscope as a bruit. A bruit does not indicate stenosis, which is when blood flow is restricted through a blood vessel. This is not a normal finding. Hypothyroidism can produce a smaller than normal thyroid gland and decreased blood flow. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 26

Type: MCSA The nurse is demonstrating palpation of the lymph nodes to a nursing student. Which of the following methods would be correct for the nurse to use during this examination? 1. First on one side, then on the other 2. Gentle, circular pressure 3. Strong, deep pressure 4. Always attempt to push the nodes into the muscle. Correct Answer: 2 Rationale 1: Nodes should be palpated on both sides simultaneously for comparison. Rationale 2: Palpation of the lymph nodes should be done by exerting gentle, circular pressure using the fingerpads of both hands. Rationale 3: Strong, deep pressure can push the nodes into the muscle and underlying structures, making them difficult to find. Rationale 4: It is not appropriate to exhibit enough pressure to push the lymph nodes into the client’s neck muscles because it makes it more difficult to find the lymph nodes. Global Rationale: Palpation of the lymph nodes should be done by exerting gentle, circular pressure using the fingerpads of both hands. Strong, deep pressure can push the nodes into the muscle and underlying structures, making them difficult to find. Nodes should be palpated on both sides simultaneously for comparison. It is not appropriate to exhibit enough pressure to push the lymph nodes into the client’s neck muscles because it makes it more difficult to find the lymph nodes. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 27 Type: MCSA The nurse is assessing a client with complaints of sudden, intermittent headaches for the past several months. The client states that the headaches come after seeing flashes of lights and experiencing nausea. The nurse would suspect which of the following disorders? 1. Migraine headaches

2. Cluster headaches 3. Tension headaches 4. Increased intracranial pressure Correct Answer: 1 Rationale 1: Migraine headaches are often preceded by an aura during which the client may feel depressed, restless, or irritable; see spots or flashes of light; and feel nausea. Rationale 2: Cluster headaches come in waves over a period of time and then disappear and reappear. Rationale 3: Tension headaches occur gradually. Rationale 4: The headache associated with increased intracranial pressure is usually sudden and severe and is not intermittent. Global Rationale: Migraine headaches are often preceded by an aura during which the client may feel depressed, restless, or irritable; see spots or flashes of light; and feel nausea. Cluster headaches come in waves over a period of time and then disappear and reappear. Tension headaches occur gradually. Neither cluster nor tension headaches are precipitated by an aura. The headache associated with increased intracranial pressure is usually sudden and severe and is not intermittent. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 28 Type: MCSA During a focused assessment and interview regarding the client’s head and neck, the client states that she is currently suffering from a severe headache that has occurred intermittently over the course of 3 days. The client denies any aura. The pain is severe and unilateral over the right side of her face. Also, the client is complaining of nasal congestion. Which of the following is the most likely diagnosis? 1. Cluster headache 2. Classic migraine 3. Tension headache 4. Hydrocephalus Correct Answer: 1

Rationale 1: Cluster headaches can occur over time. They have no associated aura. They are often unilateral and can be excruciating. Nasal congestion is commonly associated with this type of headache. Rationale 2: Migraine headaches are associated with an aura, nausea, tremors, and vertigo. Rationale 3: Tension headaches are also known as a muscle contraction headache. The onset for tension headaches is gradual and the pain is steady. Rationale 4: Hydrocephalus is not a type of headache. Global Rationale: Cluster headaches can occur over time. They have no associated aura. They are often unilateral and can be excruciating. Nasal congestion is commonly associated with this type of headache. Migraine headaches are associated with an aura, nausea, tremors, and vertigo. Tension headaches are also known as a muscle contraction headache. The onset for tension headaches is gradual and the pain is steady. Hydrocephalus is not a type of headache. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 29 Type: MCSA The nurse is assessing a newborn infant and notes that the infant’s head is enlarged with prominent scalp veins visible. The nurse would correctly document this finding as which of the following? 1. Craniosynostosis 2. Hydrocephalus 3. Acromegaly 4. Fetal alcohol syndrome Correct Answer: 2 Rationale 1: Craniosynostosis is early closure of the sutures, which causes head elongation. Rationale 2: Hydrocephalus is enlargement of the head caused by inadequate drainage of cerebrospinal fluid. Rationale 3: Acromegaly is enlargement of the skull and cranial bones due to increased growth hormone, which would not be the cause in an infant. Acromegaly is usually found in adult clients. Rationale 4: Fetal alcohol syndrome causes specific types of facial deformities such as a small head circumference, small widely spaced eyes, and a flat mid-facial area.

Global Rationale: Hydrocephalus is enlargement of the head caused by inadequate drainage of cerebrospinal fluid. Craniosynostosis is early closure of the sutures, which causes head elongation. Acromegaly is enlargement of the skull and cranial bones due to increased growth hormone, which would not be the cause in an infant. Acromegaly is usually found in adult clients. Fetal alcohol syndrome causes specific types of facial deformities such as a small head circumference, small widely spaced eyes, and a flat mid-facial area. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 30 Type: MCMA The nurse is assessing an infant diagnosed with Down syndrome. Which of the following characteristics would the nurse expect to find during the examination? Standard Text: Select all that apply. 1. Slanted eyes 2. Cleft palate and lip 3. Protruding tongue 4. Shortened neck 5. Drooping eyelids Correct Answer: 1,3,4 Rationale 1: Slanted eyes: An associated characteristic of a client with Down syndrome is slanted eyes. Rationale 2: Cleft palate and lip: Down syndrome is not associated with a cleft palate and lip. Rationale 3: Protruding tongue: An associated characteristic of a client with Down syndrome is a protruding tongue. Rationale 4: Shortened neck: An associated characteristic of a client with Down syndrome is a shortened neck. Rationale 5: Drooping eyelids: Down syndrome is not associated with drooping eyelids. Global Rationale: Associated characteristics of a client with Down syndrome are slanted eyes, a protruding tongue, and a shortened neck. Cleft palate and lip and drooping eyelids are not characteristics associated with Down syndrome.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures. Question 31 Type: MCSA 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. Eliminating the use of alcohol 2. Annual monitoring of hormone levels 3. Information about congenital abnormalities 4. Information on birth control Correct Answer: 2 Rationale 1: The ingestion of alcohol is not necessarily associated with thyroid function. Rationale 2: Production of thyroid hormone decreases with age, and older adults, regardless of gender, should have annual thyroid screening and monitoring of thyroid hormone levels. Rationale 3: Education about congenital abnormalities is most appropriate to teach to a pregnant woman with risk factors associated with these types of problems. Rationale 4: Birth control education is probably less appropriate to teach to an older adult client. Global Rationale: The ingestion of alcohol is not necessarily associated with thyroid function. Production of thyroid hormone decreases with age, and older adults, regardless of gender, should have annual thyroid screening and monitoring of thyroid hormone levels. Education about congenital abnormalities is most appropriate to teach to a pregnant woman with risk factors associated with these types of problems. Birth control education is probably less appropriate to teach to an older adult client. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. 5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 32 Type: MCMA

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? Standard Text: Select all that apply. 1. The parents of a newborn should be educated about the clinical manifestations associated with hyperthyroidism. 2. Thyroid disease more frequently affects males than females. 3. Immigrants may have an increased risk of disorders related to thyroid function. 4. Depression in older adults may be linked to hypothyroidism. 5. The iodine added to some medications can be linked to hypothyroidism in the clients who use these medications. Correct Answer: 1,2,5 Rationale 1: The parents of a newborn should be educated about the clinical manifestations associated with hyperthyroidism. Parents of newborns should be educated about the clinical manifestations associated with hypothyroidism. Hypothyroidism in newborns is a very serious condition and may even be fatal. Rationale 2: Thyroid disease more frequently affects males than females. Women are more likely to develop thyroid disease. Women are advised to have thyroid screening diagnostic tests performed if they have a family history of the disease. Rationale 3: Immigrants may have an increased risk of disorders related to thyroid function. Iodine deficiency leads to thyroid dysfunction and may occur more often in immigrant populations. Rationale 4: Depression in older adults may be linked to hypothyroidism. Older adults with depression should be evaluated for hypothyroidism. Rationale 5: The iodine added to some medications may be linked to hypothyroidism in the clients who use these medications. Medications with iodine can increase the client’s risk of developing hyperthyroidism, not hypothyroidism. Global Rationale: Parents of newborns should be educated about the clinical manifestations associated with hypothyroidism. Hypothyroidism in newborns is a very serious condition and may even be fatal. Women are more likely to develop thyroid disease. Women are advised to have thyroid screening diagnostic tests performed if they have a family history of the disease. Iodine deficiency leads to thyroid dysfunction and may occur more often in immigrant populations. Older adults with depression should be evaluated for hypothyroidism. Medications with iodine can increase the client’s risk of developing hyperthyroidism, not hypothyroidism. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12.6: Discuss the objectives related to the overall health of the head, neck, and related lymphatics as presented in Healthy People 2020. Question 33 Type: MCMA The nurse is assessing the client. The client is irritable, anxious, and has lost 12 pounds over the last 2 months. The client’s eyes appear to bulge from their sockets. Which of the following pieces of information does the nurse expect to find during the assessment of this client? Standard Text: Select all that apply. 1. Blood pressure: 162/92 2. Apical pulse: 120 3. Respiratory rate: 11 4. Pupils: constricted 5. Client complains of feeling very warm. Correct Answer: 1,2,5 Rationale 1: Blood pressure: 162/92. When the sympathetic nervous system is stimulated due to hyperthyroidism, the client’s blood pressure will increase. This blood pressure is increased. Rationale 2: Apical pulse: 120. When the sympathetic nervous system is stimulated due to hyperthyroidism, the client’s heart rate will increase. A normal heart rate for an adult client is 60–100 beats per minute. Rationale 3: Respiratory rate: 11. The client with hyperthyroidism will demonstrate an increased respiratory rate. A normal respiratory rate is 12–20 per minute. Rationale 4: Pupils: constricted. The client with hyperthyroidism will demonstrate pupil dilation. Rationale 5: Client complains of feeling very warm. When the sympathetic nervous system is stimulated due to hyperthyroidism, the client’s body temperature will increase. Global Rationale: When the sympathetic nervous system is stimulated due to hyperthyroidism, the client’s blood pressure, heart rate, and body temperature will increase. This blood pressure and heart rate are increased. Complaints of feeling warm are related to increased body temperature. The client with hyperthyroidism will demonstrate an increased respiratory rate. A normal respiratory rate is 12–20 per minute. The client with hyperthyroidism will demonstrate pupil dilation. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.7: Apply critical thinking in selected simulations related to physical assessment of the head, neck, and related structures.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 13 Question 1 Type: MCMA The nurse is assessing a client who is 34 weeks pregnant. Which of the following visual changes are usually normal in this stage in pregnancy and should disappear at some point after delivery? Standard Text: Select all that apply. 1. The client is complaining that her eyes feel very dry. 2. She states that she is experiencing blurry vision. 3. Periorbital edema is noted. 4. Cataracts are noted. 5. She has been unable to wear her contact lenses. Correct Answer: 1,2,5 Rationale 1: The client is complaining that her eyes feel very dry. The pregnant client may complain of dry eyes. This symptom is usually not significant and disappears after childbirth. Rationale 2: She states that she is experiencing blurry vision. The pregnant client may describe visual changes such as blurry vision due to shifting fluid within the eye. Blurriness or distorted vision can occur because of temporary changes in the shape of the eye during the last trimester of pregnancy. Rationale 3: Periorbital edema is noted. Eyelid edema is not a common problem associated with pregnancy. Periorbital edema may signal an underlying problem. Rationale 4: Cataracts are noted. Cataracts are not commonly associated with pregnancy. Rationale 5: She has been unable to wear her contact lenses. Pregnant women often discontinue wearing their contact lenses during their pregnancy as a result of fit and comfort. Global Rationale: The pregnant client may complain of dry eyes. This symptom is usually not significant and disappears after childbirth. The pregnant client may describe visual changes such as blurry vision due to shifting fluid within the eye. Blurriness or distorted vision can occur because of temporary changes in the shape of the eye during the last trimester of pregnancy. Pregnant women often discontinue wearing their contact lenses during their pregnancy as a result of fit and comfort. Eyelid edema is not a common problem associated with pregnancy. Periorbital edema may signal an underlying problem. Cataracts are not commonly associated with pregnancy. Cognitive Level: Applying Client Need: Health Promotion and Maintenance

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye. Question 2 Type: MCSA The nurse noted that the client was unable to control the amount of light that came into her eye. The dysfunction of which of the following structures is the most likely cause of this problem? 1. Cornea 2. Sclera 3. Conjunctiva 4. Iris Correct Answer: 4 Rationale 1: The cornea is the window of the eye. It is the clear, transparent part of the sclera and forms the anterior one sixth of the eye. Rationale 2: The sclera supports and protects the structures of the eye. Rationale 3: The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye from becoming too dry. Rationale 4: The iris responds to the light coming through the cornea by making the pupil larger or smaller, thereby controlling the amount of light that enters the eye. Global Rationale: The cornea is the window of the eye. It is the clear, transparent part of the sclera and forms the anterior one sixth of the eye. The sclera supports and protects the structures of the eye. The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye from becoming too dry. The iris responds to the light coming through the cornea by making the pupil larger or smaller, thereby controlling the amount of light that enters the eye. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye. Question 3 Type: MCMA The nurse is examining the eye. The client asks about the specific structures within the eye that are responsible for refraction of light rays. The nurse accurately states that the following structures are involved in this process:

Standard Text: Select all that apply. 1. Lens 2. Macula 3. Cornea 4. Iris 5. Optic disc Correct Answer: 1,3 Rationale 1: Lens. The lens is located directly behind the pupil and is used to refract light through the eye. Rationale 2: Macula. The macula is located within the retina and does not assist with light refraction. Rationale 3: Cornea. The cornea is a transparent part of the eye and located anteriorly. It allows light to enter the eye and assists with refraction. Rationale 4: Iris. The iris controls the amount of light that enters the eye, but is not associated with refraction. Rationale 5: Optic disc. The optic disc is where the optic nerve and retina meet. It is where the vascular network enters the eye. This structure is not associated with refraction. Global Rationale: The lens is located directly behind the pupil and is used to refract light through the eye. The macula is located within the retina and does not assist with light refraction. The cornea is a transparent part of the eye and located anteriorly. It allows light to enter the eye and assists with refraction. The iris controls the amount of light that enters the eye, but is not associated with refraction. The optic disc is where the optic nerve and retina meet. It is where the vascular network enters the eye. This structure is not associated with refraction. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye. Question 4 Type: MCSA The nurse taught the client how to self-administer eye drops and the client was performing a return demonstration. During this time, the client inadvertently touched the applicator to their cornea, which caused the client to blink and produce tears. The nurse may document this response as which of the following? 1. Abnormal and should be reported to the healthcare provider 2. Hyperactive

3. A medication side effect 4. A normal response Correct Answer: 4 Rationale 1: When the cornea is touched, the eyelids blink and tears are produced. The cornea contains many nerve endings and this action would produce a painful sensation for the client. This is not an abnormal response. Rationale 2: This would not be noted as a hyperactive response. Rationale 3: This is not due to a medication side effect. Rationale 4: This is a normal response because the cornea is very sensitive. Global Rationale: When the cornea is touched, the eyelids blink and tears are produced. The cornea contains many nerve endings and this action would produce a painful sensation for the client. This is not an abnormal response. This would not be noted as a hyperactive response. This is not due to a medication side effect. This is a normal response because the cornea is very sensitive. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye. Question 5 Type: MCHS The client requests information about where visual information is processed within the brain. Draw an arrow pointing to the location of the occipital lobe.

Correct Answer: Rationale : Optic tracts encircle the brain and the impulses are transmitted to the occipital lobe of the brain for interpretation. Global Rationale: Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye. Question 6 Type: MCMA The nurse is assessing the client’s eyes during a comprehensive health assessment. Which of the following pieces of information should the nurse also gather? Standard Text: Select all that apply. 1. The client is 62 years old. 2. The client’s parents were born in Spain. 3. The client’s annual income is below the poverty level. 4. The client is a welder. 5. The client recently attempted to commit suicide after his wife died in an automobile accident. Correct Answer: 1,2,3,4,5 Rationale 1: The client is 62 years old. During a comprehensive health assessment, it is important to gather objective information such as the client’s age.

Rationale 2: The client’s parents were born in Spain. During a comprehensive health assessment, it is important to gather information about the client’s ethnicity and race. Ethnicity may influence how a client performs self-care activities. Hispanics have higher rates of visual impairments than other races. Rationale 3: The client’s annual income is below the poverty level. During a comprehensive health assessment, it is important to gather information about the client’s socioeconomic status. This may affect how often the client will visit a health care provider for his health care needs and routine screening activities. Rationale 4: The client is a welder. During a comprehensive health assessment, it is important to gather information about the client’s occupation. People who work in some settings are more likely to experience eye injuries. Rationale 5: The client recently attempted to commit suicide after his wife died in an automobile accident. During a comprehensive health assessment, it is important to gather information about the client’s emotional wellbeing. Global Rationale: During a comprehensive health assessment, it is important to gather objective information such as the client’s age. It is also important to gather information about the client’s ethnicity and race. Ethnicity may influence how a client performs self-care activities. Hispanics have higher rates of visual impairments than other races. It is important to gather information about the client’s socioeconomic status. This may affect how often the client will visit a health care provider for his health care needs and routine screening activities. It is important to gather information about the client’s occupation. People who work in some settings are more likely to experience eye injuries. It is important to gather information about the client’s emotional well-being. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye. Question 7 Type: MCSA The nurse is interviewing the mother of a three-week-old Caucasian infant. Which statement by the mother indicates she requires further education about her infant’s eyes? 1. “It’s normal for my baby not to produce tears when she cries.” 2. “At this stage, my baby should be able to fixate on a bright light or something that moves.” 3. “My baby’s eyes are blue and definitely will stay blue.” 4. “It was normal for my baby’s eyes to be swollen after birth.” Correct Answer: 3 Rationale 1: At this stage, the baby may not be able to produce tears. By the fourth week, the baby will begin to produce tears.

Rationale 2: At six weeks, the baby will begin to develop binocular vision. At this stage, the baby will fixate on a bright light or a moving object. Rationale 3: Light-skinned infants are born with blue eyes. By about the third month of age, the color of the eyes begins to change to a more permanent shade. Rationale 4: At birth, many infants have edematous eyelids. Global Rationale: At this stage, the baby may not be able to produce tears. By the fourth week, the baby will begin to produce tears. At six weeks, the baby will begin to develop binocular vision. At this stage, the baby will fixate on a bright light or a moving object. Light-skinned infants are born with blue eyes. By about the third month of age, the color of the eyes begins to change to a more permanent shade. Before six weeks of age, infants will fixate on a bright or moving object. At birth, many infants have edematous eyelids. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye. Question 8 Type: MCSA 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. There is a noticeable increase in fat within the orbit of the eye. 3. The client states that she feels her tear production has increased over the years. 4. The pupillary light reflex is slower bilaterally. Correct Answer: 4 Rationale 1: The lens of the older client’s eye is less elastic and the client’s ciliary muscles will become weaker. This results in a decreased ability to focus on objects that are held at close range. Rationale 2: There is a decrease in the amount of fat in the orbit of the eye, which produces a drooping appearance of the eye. Rationale 3: Older adults experience a decrease in lacrimal secretions. Rationale 4: The pupillary light reflex slows with age. Global Rationale: The lens of the older client’s eye is less elastic and the client’s ciliary muscles will become weaker. This results in a decreased ability to focus on objects that are held at close range. There is a decrease in

the amount of fat in the orbit of the eye, which produces a drooping appearance of the eye. Older adults experience a decrease in lacrimal secretions. The pupillary light reflex slows with age. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye. Question 9 Type: MCSA The nurse is performing a visual examination on a client due to the client’s complaints of black dots appearing in the visual field. Which of the following statement is the nurse’s best response to the client? 1. “The black dots are known as floaters and are usually normal.” 2. “We need to refer you to an eye surgeon immediately.” 3. “You may have glaucoma.” 4. “You may have a cataract.” Correct Answer: 1 Rationale 1: Black dots or spots are known as floaters. Floaters are considered normal unless they obstruct vision, so they should not be immediately referred to a healthcare provider. Rationale 2: Floaters are considered normal unless they obstruct vision, so they should not be immediately referred to a healthcare provider. Rationale 3: Halos around lights are associated with glaucoma. Rationale 4: Floaters are not seen with cataracts. Global Rationale: Black dots or spots are known as floaters. Floaters are considered normal unless they obstruct vision, so they should not be immediately referred to a healthcare provider. Halos around lights are associated with glaucoma. Floaters are not seen with cataracts. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2: Develop questions to be used when completing the focused interview. Question 10 Type: MCSA

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 graduated from college. 2. The client interacts easily with the nurse. 3. The client is an African American male. 4. The client is 23 years old. Correct Answer: 2 Rationale 1: It is important to determine the client’s educational level. Rationale 2: The client’s ability to communicate is most essential to the interview. The nurse must determine how well the client will be able to participate in the focused interview and follow directions during the physical assessment. Rationale 3: It is important to assess the client’s race because this may influence what types of eye conditions the client is at risk for developing. Rationale 4: The client’s age is important to assess because anatomical and physiologic changes can occur in the eye across the lifespan. Global Rationale: The client’s ability to communicate is most essential to the interview. The nurse must determine how well the client will be able to participate in the focused interview and follow directions during the physical assessment. It is important to determine the client’s educational level. It is important to assess the client’s race because this may influence what types of eye conditions the client is at risk for developing. The client’s age is important to assess because anatomical and physiologic changes can occur in the eye across the lifespan. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2: Develop questions to be used when completing the focused interview. Question 11 Type: MCSA A client was referred to the clinic with complaints of blurred vision. The initial question for the nurse to ask the client would be which of the following? 1. “Would you please tell me about your vision today?” 2. “Do you experience double vision?” 3. “Have you had any eye pain?”

4. “What kinds of activities do you perform at work?” Correct Answer: 1 Rationale 1: The best way to start the focused interview is to begin with open-ended questions that provide the client with an opportunity to describe his own perceptions about his vision. Rationale 2: Information about double vision is important, but not the best way to start the interview. Rationale 3: Information about eye pain is important, but not the best way to start the interview. Rationale 4: Information about work activities is important, but not the best way to start the interview. Global Rationale: The best way to start the focused interview is to begin with open-ended questions that provide the client with an opportunity to describe his own perceptions about his vision. All of the other questions are appropriate to ask at some point during the focused interview but are not the best way to start the interview. It is important to determine if the client has experienced double vision. Double vision can be caused by muscle or nerve problems and some types of medications. It is important to determine if the client is experiencing eye pain because it can be associated with glaucoma or other eye problems. It is important to determine the client’s occupation because some types of occupations put the client at risk for eye injury or eyestrain. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2: Develop questions to be used when completing the focused interview. Question 12 Type: MCSA During an eye assessment, a 24-year-old client reports difficulty seeing items well at close range. The nurse realizes this finding is consistent with: 1. aging. 2. presbyopia. 3. hyperopia. 4. astigmatism. Correct Answer: 3 Rationale 1: Aging can produce changes in the eye but this client is 24 years old. Rationale 2: Presbyopia is an age-related condition. The lens loses its ability to accommodate viewing items at close range.

Rationale 3: Younger clients who are unable to see items well at close range have a condition called hyperopia. This condition is also referred to as farsightedness. Rationale 4: Astigmatism occurs when light is refracted over a wide area rather than on a distinct area of the retina. Global Rationale: Younger clients who are unable to see items well at close range have a condition called hyperopia. This condition is also referred to as farsightedness. Aging can produce changes in the eye but this client is 24 years old. Presbyopia is an age-related condition. The lens loses its ability to accommodate viewing items at close range. Astigmatism occurs when light is refracted over a wide area rather than on a distinct area of the retina. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.3: Describe the techniques required for assessment of the eye. Question 13 Type: MCSA The nurse notices that a client’s pupils constrict when reading the consent form for medical treatment. This observation would lead the nurse to consider which of the following? 1. The room is too dark. 2. The client is able to read. 3. This is a normal response. 4. The client requires glasses for reading. Correct Answer: 3 Rationale 1: When a room is dark, the client’s pupils should dilate in response. Rationale 2: Pupil constriction occurs as the client focuses on the paper. It does not indicate the client can read. Rationale 3: This is a normal finding. The client’s pupils should constrict in response to trying to read what is on the paper. Rationale 4: Pupil constriction would not lead the nurse to believe the client needs reading glasses. Global Rationale: When a room is dark, the client’s pupils should dilate in response. Pupil constriction occurs as the client focuses on the paper. It does not indicate the client can read. This is a normal finding. The client’s pupils should constrict in response to trying to read what is on the paper. Pupil constriction would not lead the nurse to believe the client needs reading glasses.

Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.3: Describe the techniques required for assessment of the eye. Question 14 Type: MCMA During an eye examination, the nurse requests that the client read letters located on the Snellen E chart. The client’s vision is determined to be 20/200. Which of the following is true regarding these findings? Standard Text: Select all that apply. 1. The client is legally blind. 2. The client is unable to read from a paper at close range. 3. The client is found to be farsighted. 4. The client is myopic. 5. This is common in clients who are over 45 years old. Correct Answer: 1,4 Rationale 1: The client is legally blind. When a client’s vision is found to be 20/200, the client is legally blind. Rationale 2: The client is unable to read from a paper at close range. The Snellen E chart assists with determining if the client is able to see items in the distance. Rationale 3: The client is found to be farsighted. Clients who are farsighted are able to see things in the distance. This client is unable to see distant objects. Rationale 4: The client is myopic. Clients who are myopic are unable to see objects in the distance. Rationale 5: This is common in clients who are over 45 years old. Presbyopia is the inability to see items at close range. This condition is more common in people who are over 45 years old. Global Rationale: When a client’s vision is found to be 20/200, the client is legally blind. The Snellen E chart assists with determining if the client is able to see items in the distance. Clients who are farsighted are able to see things in the distance. This client is unable to see distant objects. Clients who are myopic are unable to see objects in the distance. Presbyopia is the inability to see items at close range. This condition is more common in people who are over 45 years old. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.3: Describe the techniques required for assessment of the eye. Question 15 Type: MCSA The nurse is assessing a client’s visual fields by confrontation. Which of the following nursing actions indicates that the nurse requires further education regarding this test? 1. The nurse asks the client to cover one of her eyes with a card. 2. The nurse uses a penlight to assist with performing the test. 3. The nurse asks the client to sit 20 feet away. 4. The client tells the nurse when she first sees the object. Correct Answer: 3 Rationale 1: Confrontation to test visual fields is done by asking the client to cover one eye with a cover while the nurse covers the eye opposite to the client. Rationale 2: The nurse and client sit 2–3 feet away from each other, at eye level. An object such as a pen or penlight is advanced from the periphery to the midline. Both the client and the nurse should be able to see the object at the same time. Rationale 3: The nurse and client should sit only 2–3 feet away from each other. Rationale 4: The client should tell the nurse when she first sees the object in her peripheral vision. Global Rationale: Confrontation to test visual fields is done by asking the client to cover one eye with a cover while the nurse covers the eye opposite to the client. The nurse and client sit 2–3 feet away from each other, at eye level. An object such as a pen or penlight is advanced from the periphery to the midline. Both the client and the nurse should be able to see the object at the same time. The nurse and client should sit only 2–3 feet away from each other. The client should tell the nurse when she first sees the object in her peripheral vision. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.3: Describe the techniques required for assessment of the eye. Question 16 Type: HOTSPOT The nurse is assessing the client’s corneal reflex. Draw an arrow pointing to the area of the eye that the nurse should test for the presence of this reflex.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The nurse should use a lateral approach and gently touch the client’s cornea on the outer aspect. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.3: Describe the techniques required for assessment of the eye. Question 17 Type: MCSA The nurse is assessing the client’s eye with an ophthalmoscope. The nurse is preparing to focus on the fundus and rotates the lens diopter wheel into the negative numbers. Based on this information, which of the following conditions does the client most likely have? 1. Hyperopia 2. Presbyopia 3. Myopia

4. Astigmatism Correct Answer: 3 Rationale 1: The diopter is rotated toward the positive numbers when the client is hyperopic. Rationale 2: For presbyopia the diopter wheel is rotated until the fundus can be visualized adequately. Rationale 3: The diopter wheel is rotated into the negative numbers when the client is myopic. Rationale 4: For astigmatism the diopter wheel is rotated until the fundus can be visualized adequately. Global Rationale: The diopter is rotated to help the nurse focus on the client’s fundus. The diopter is rotated toward the positive numbers when the client is hyperopic. The diopter wheel is rotated into the negative numbers when the client is myopic. For any other condition such as presbyopia or astigmatism, the diopter wheel is rotated until the fundus can be visualized adequately. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.4: Explain the use of the ophthalmoscope. Question 18 Type: HOTSPOT The nurse is assessing the client’s retina. Draw an arrow pointing toward the location of the optic disc.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The optic disc can be identified by following the path of the blood vessels. As they grow larger, they lead to the optic disc which is located on the nasal side of the retina. The optic disc normally looks like a round or oval yellow-orange depression with a distinct margin. This is the site where the optic nerve and blood vessels exit from the eye. Global Rationale: Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.4: Explain the use of the ophthalmoscope. Question 19 Type: MCSA 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. Impaired peripheral vision 3. Consistently elevated serum glucose levels 4. Uncontrolled hypertension Correct Answer: 1 Rationale 1: Degeneration of the macula can be related to cysts located in this area. It is more common in older adults and results in impaired central vision. Rationale 2: Impaired peripheral vision can be related to problems with the rods that are located in the retina. Rationale 3: Elevated serum glucose levels may be associated with diabetic retinopathy.

Rationale 4: Uncontrolled hypertension can be associated with hypertensive retinopathy. Global Rationale: Degeneration of the macula can be related to cysts located in this area. It is more common in older adults and results in impaired central vision. Impaired peripheral vision can be related to problems with the rods that are located in the retina. Elevated serum glucose levels may be associated with diabetic retinopathy. Uncontrolled hypertension can be associated with hypertensive retinopathy. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.4: Explain the use of the ophthalmoscope Question 20 Type: MCSA 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 examine the client’s right eye with my left eye.” 2. “I’m going to advance the ophthalmoscope until the instrument touches the client’s cornea.” 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.” Correct Answer: 3 Rationale 1: The nurse should prepare to assess the client’s eye with an ophthalmoscope by examining the client’s right eye with the nurse’s right eye. Rationale 2: The nurse should advance the ophthalmoscope only until it almost touches the client’s eyelashes. The cornea contains many nerve endings and this would be painful for the client. Rationale 3: The nurse should always begin with the lens set to the 0 diopter. Rationale 4: The red reflex is seen as light reflects off of the client’s retina, not his lens. Global Rationale: The nurse should always begin with the lens set to the 0 diopter. The nurse should prepare to assess the client’s eye with an ophthalmoscope by examining the client’s right eye with the nurse’s right eye. The nurse should advance the ophthalmoscope only until it almost touches the client’s eyelashes. The cornea contains many nerve endings and this would be painful for the client. The red reflex is seen as light reflects off of the client’s retina, not his lens. Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.4: Explain the use of the ophthalmoscope. Question 21 Type: MCSA The nurse is assessing a client’s eyes during a comprehensive health assessment. The nurse knows that the client who demonstrates clinical manifestations of which of the following conditions will require immediate intervention? 1. Acute glaucoma 2. Blepharitis 3. Periorbital edema 4. Anisocoria Correct Answer: 1 Rationale 1: Acute glaucoma results from a sudden increase in intraocular pressure caused by a blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate interventions to prevent further eye damage. Rationale 2: Blepharitis is when the eyelid becomes inflamed. The eye burns, itches, and tears but does not require an immediate intervention. Rationale 3: Periorbital edema is when the eyelid becomes puffy and swollen. It can be related to crying, infection, or systemic problems. It does not require an immediate intervention. Rationale 4: Anisocoria refers to unequal pupil size, which may be a normal finding or it may indicate that the client has a central nervous system disease. Global Rationale: Acute glaucoma results from a sudden increase in intraocular pressure caused by a blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate interventions to prevent further eye damage. Blepharitis is when the eyelid becomes inflamed. The eye burns, itches, and tears but does not require an immediate intervention. Periorbital edema is when the eyelid becomes puffy and swollen. It can be related to crying, infection, or systemic problems. It does not require an immediate intervention. Anisocoria refers to unequal pupil size, which may be a normal finding or it may indicate that the client has a central nervous system disease. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.

Question 22 Type: MCSA The nurse is performing the cover test and notes inward turning of the eye. Which of the following ways will the nurse accurately document this finding? 1. Exophoria 2. Strabismus 3. Esophoria 4. Mydriasis Correct Answer: 3 Rationale 1: Exophoria is when the eye turns outward during the cover test. Rationale 2: Strabismus is when the axes of the eye cannot be directed at the same object. Rationale 3: Esophoria is when the eye turns inward during the cover test. Rationale 4: Mydriasis refers to fixed and dilated pupils. Global Rationale: Exophoria is when the eye turns outward during the cover test. Strabismus is when the axes of the eye cannot be directed at the same object. Esophoria is when the eye turns inward during the cover test. Mydriasis refers to fixed and dilated pupils. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment. Question 23 Type: MCSA A client is found to need corrective lenses for myopia. Which of the following explanations would the nurse provide to this client? 1. “Your glasses will help you to see objects in the distance.” 2. “Your glasses will help you to see objects that are very close to you.” 3. “Your glasses will help you to improve your eyes’ ability to focus and reduce your blurred vision.” 4. “Your age has made it more difficult to read items that are at close range. Your new glasses will help.”

Correct Answer: 1 Rationale 1: Myopia is the inability to see objects in the distance. Rationale 2: Hyperopia is the inability to see objects at close range. Rationale 3: Astigmatism causes blurred or double vision when the eyes attempt to focus. Rationale 4: Presbyopia causes the client to experience difficulty focusing on items that are at close range. Presbyopia affects people who are over 45 years old. Global Rationale: Myopia is the inability to see objects in the distance. Hyperopia is the inability to see objects at close range. Astigmatism causes blurred or double vision when the eyes attempt to focus. Presbyopia causes the client to experience difficulty focusing on items that are at close range. Presbyopia affects people who are over 45 years old. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment. Question 24 Type: MCSA The nurse is assessing the client’s pupillary responses. The client is found to have no consensual response. The finding indicates which of the following to the nurse? 1. Cranial nerve III may not be functioning appropriately. 2. This is a normal finding. 3. This is evidence of increased intracranial pressure. 4. This is evidence of optic nerve damage. Correct Answer: 1 Rationale 1: When evaluating pupillary response, the unilluminated, or consensual, pupil should also constrict. When this does not occur, it may be indicative of problems associated with cranial nerve III. Rationale 2: This is not a normal finding. Rationale 3: Increased intracranial pressure is associated with pupils that are unequal and irregularly shaped. Rationale 4: This is not evidence that optic nerve damage has occurred. Optic nerve damage can produce changes in the client’s visual fields.

Global Rationale: When evaluating pupillary response, the unilluminated, or consensual, pupil should also constrict. When this does not occur, it may be indicative of problems associated with cranial nerve III. This is not a normal finding. Increased intracranial pressure is associated with pupils that are unequal and irregularly shaped. This is not evidence that optic nerve damage has occurred. Optic nerve damage can produce changes in the client’s visual fields. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment. Question 25 Type: MCSA During the assessment of a client’s eyes, the nurse suspects the client has entropian. Which of the following did the nurse most likely find while assessing this client? 1. Eversion of the lower eyelid 2. Inversion of the lid and eyelashes 3. Swollen, red hair follicles 4. Firm, nontender nodule on the eyelid Correct Answer: 2 Rationale 1: Ectropian is eversion of the lower eyelid caused by muscle weakness. Rationale 2: Entropian is inversion of the lid and lashes caused by a muscle spasm of the eyelid. Rationale 3: A stye causes swelling and redness in the affected eye. A stye is a result of a staphylococcal infection of hair follicles on the margin of the lids. Rationale 4: A chalazion is a firm, nontender nodule on the eyelid. Global Rationale: Entropian is inversion of the lid and lashes caused by a muscle spasm of the eyelid. Ectropian is eversion of the lower eyelid caused by muscle weakness. A stye causes swelling and redness in the affected eye. A stye is a result of a staphylococcal infection of hair follicles on the margin of the lids. A chalazion is a firm, nontender nodule on the eyelid. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.

Question 26 Type: MCSA During the assessment of a client’s eyes, the nurse suspects that the client has ptosis. Which of the following did the nurse most likely find? 1. The palpebral conjunctiva is exposed. 2. The iris and cornea are reddened. 3. The eyelid is drooping. 4. The eyelids are swollen and puffy. Correct Answer: 3 Rationale 1: Ectropian is eversion of the lower eyelid caused by muscle weakness that produces exposure of the palpebral conjunctiva. Rationale 2: Iritis is characterized by redness of the iris and cornea. Rationale 3: Ptosis is drooping of the eyelid. Rationale 4: Periorbital edema refers to swollen, puffy eyelids. Global Rationale: Ptosis is drooping of the eyelid. Ectropian is eversion of the lower eyelid caused by muscle weakness that produces exposure of the palpebral conjunctiva. Iritis is characterized by redness of the iris and cornea. Periorbital edema refers to swollen, puffy eyelids. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment. Question 27 Type: MCSA The nurse is assessing an adult African American client who is experiencing visual changes. Which of the following questions would be the most important to ask this client? 1. “Have you or anyone in your family ever been diagnosed with diabetes?” 2. “Do you wear sunglasses when you are outside?” 3. “Did your mother have a vaginal infection at the time of your delivery?” 4. “Do you see any halos around lights?”

Correct Answer: 1 Rationale 1: Diabetic retinopathy is the leading cause of blindness in the United States. It is important for the nurse to determine if the client has a personal or family history of diabetes. Type 2 diabetes occurs more frequently in African Americans, Asian Americans, Hispanic Americans, and Native Americans than in Caucasian clients. This will assist the nurse to determine if the client may be suffering visual changes as a result of diabetic retinopathy. Rationale 2: The nurse can ask about the client’s behaviors to determine his risk of developing problems associated with ultraviolet radiation. Rationale 3: When the nurse is assessing an infant, the nurse should inquire about whether the mother of the infant had a vaginal infection at the time of delivery because this can result in eye infections in the newborn. Rationale 4: Clients who see halos around lights may be suffering from glaucoma and increased intraocular pressure. Global Rationale: Diabetic retinopathy is the leading cause of blindness in the United States. It is important for the nurse to determine if the client has a personal or family history of diabetes. Type 2 diabetes occurs more frequently in African Americans, Asian Americans, Hispanic Americans, and Native Americans than in Caucasian clients. This will assist the nurse to determine if the client may be suffering visual changes as a result of diabetic retinopathy. The nurse can ask about the client’s behaviors to determine his risk of developing problems associated with ultraviolet radiation. When the nurse is assessing an infant, the nurse should inquire about whether the mother of the infant had a vaginal infection at the time of delivery because this can result in eye infections in the newborn. Clients who see halos around lights may be suffering from glaucoma and increased intraocular pressure. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the eye. Question 28 Type: MCMA The nurse is assessing a child previously diagnosed with fetal alcohol syndrome. Which of the following statements by the client’s adoptive mother are consistent with the child’s diagnosis? Standard Text: Select all that apply. 1. “It seems as if one of his eyelids is droopy.” 2. “There’s a firm little bump on his eyelid but he says it doesn’t hurt.” 3. “His eyes almost look cloudy.”

4. “He has required glasses to see well since he was 2 years old.” 5. “His eyelids look they have turned under and he complains that his eyes hurt.” Correct Answer: 1,3,4 Rationale 1: “It seems as if one of his eyelids is droopy.” A child with fetal alcohol syndrome may experience ptosis. Rationale 2: “There’s a firm little bump on his eyelid but he says it doesn’t hurt.” Chalazions are firm, nontender nodules located on the eyelids that are associated with infection. They are not associated with fetal alcohol syndrome. Rationale 3: “His eyes almost look cloudy.” Cataracts are associated with children who have been diagnosed with fetal alcohol syndrome. Rationale 4: “He has required glasses to see well since he was 2 years old.” Structural abnormalities of the eye are associated with fetal alcohol syndrome. These abnormalities may result in reduced visual acuity. Rationale 5: “His eyelids look like they have turned under and he complains that his eyes hurt.” Entropion is when the eyelids invert and the lashes can scratch the cornea. Entropion is not associated with fetal alcohol syndrome. Global Rationale: A child with fetal alcohol syndrome may experience ptosis. Chalazions are firm, nontender nodules located on the eyelids that are associated with infection. They are not associated with fetal alcohol syndrome. Cataracts are associated with children who have been diagnosed with fetal alcohol syndrome. Structural abnormalities of the eye are associated with fetal alcohol syndrome. These abnormalities may result in reduced visual acuity. Entropion is when the eyelids invert and the lashes can scratch the cornea. Entropion is not associated with fetal alcohol syndrome. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the eye. Question 29 Type: MCSA The nurse is preparing to discuss the cultural implications associated with eye diseases with a small group of nursing students. Which of the following statement indicates that the nurse requires further education about this subject? 1. “It is important to assess the African American client for clinical manifestations associated with increased intraocular pressure.” 2. “We should assess serum glucose levels in our adult Hispanic clients.”

3. “Our diabetic clients should return every 2 years for an assessment of their vision and their retina.” 4. “Poorly controlled serum glucose levels can result in retinal changes that affect the client’s vision and can even result in blindness.” Correct Answer: 3 Rationale 1: African Americans have a higher risk for developing glaucoma. Glaucoma occurs when the flow of fluid around the anterior chamber of the eye is blocked and the client’s intraocular pressure increases. Rationale 2: Hispanics are more likely to develop type 2 diabetes which can increase their risk of developing visual changes associated with diabetic retinopathy. Rationale 3: A client who has a personal or family history of diabetes should return each year for a thorough examination of his vision and retina. Diabetic retinopathy is the leading cause of blindness in the United States. Rationale 4: Poorly controlled serum glucose levels are associated with diabetes. The client with diabetes can develop diabetic retinopathy. The client with this condition can develop changes in his retina and circulatory system. Global Rationale: African Americans have a higher risk for developing glaucoma. Glaucoma occurs when the flow of fluid around the anterior chamber of the eye is blocked and the client’s intraocular pressure increases. Hispanics are more likely to develop type 2 diabetes, which can increase their risk of developing visual changes associated with diabetic retinopathy. A client who has a personal or family history of diabetes should return each year for a thorough examination of his vision and retina. Diabetic retinopathy is the leading cause of blindness in the United States. Poorly controlled serum glucose levels are associated with diabetes. The client with diabetes can develop diabetic retinopathy. The client with this condition can develop changes in his retina and circulatory system. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the eye. Question 30 Type: MCSA 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 4-year-old doesn’t need his vision screened.” 2. “I’m going to call my eye doctor and ask that she performs a dilated eye exam.” 3. “My mom has been complaining of dry eyes, but I knew it was all in her head.”

4. “I didn’t know that Asians have the highest risk for developing glaucoma.” Correct Answer: 2 Rationale 1: Preschooler-aged children should have their vision screened to detect problems early. Early detection can lead to early treatment. Rationale 2: One of the objectives of Healthy People 2020 is to increase the number of people who have dilated eye examinations performed. This is a screening method that can lead to early detection of eye problems. Rationale 3: Older adults have a decrease in tear secretions that result in complaints of dry eyes. Rationale 4: African Americans have the greatest risk for developing glaucoma when compared to other racial groups. Global Rationale: Preschooler-aged children should have their vision screened to detect problems early. Early detection can lead to early treatment. One of the objectives of Healthy People 2020 is to increase the number of people who have dilated eye examinations performed. This is a screening method that can lead to early detection of eye problems. Older adults have a decrease in tear secretions that result in complaints of dry eyes. African Americans have the greatest risk for developing glaucoma when compared to other racial groups. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.7: Discuss the objectives related to overall health of the eyes and vision as presented in Healthy People 2020. Question 31 Type: MCMA The nurse is performing a focused interview and eye assessment on a client. The nurse suspects that the client is experiencing problems associated with her vision based on which of the following pieces of data? Standard Text: Select all that apply. 1. The client is frowning and squinting while she is reading the Snellen chart. 2. The client exhibits a symmetrical pupillary light reflex response. 3. As the nurse checks for accommodation, the pupils remain dilated. 4. The client’s near vision acuity is 14/14 bilaterally. 5. When the cornea is lightly touched in the right eye, both eyelids close. Correct Answer: 1,3

Rationale 1: The client is frowning and squinting while she is reading the Snellen chart. If the client is frowning or squinting during the test of their ability to see distant objects, this is indicator that the client may be experiencing visual problems. Rationale 2: The client exhibits a symmetrical pupillary light reflex response. Symmetrical pupillary responses are normal. Rationale 3: As the nurse checks for accommodation, the pupils remain dilated. When checking accommodation, the eyes should converge and the pupils should constrict as the eyes focus on the penlight. Rationale 4: The client’s near vision acuity is 14/14 bilaterally. The normal result for near vision is 14/14 in each eye. Rationale 5: When the cornea is lightly touched in the right eye, both eyelids close. When testing the corneal reflex, touch the eye gently and quickly with a wisp of cotton. The client will react by blinking both eyes. If one or both eyes fail to respond, there could be a problem. Global Rationale: If the client is frowning or squinting during the test of her ability to see distant objects, this is indicator that the client may be experiencing visual problems. Symmetrical pupillary responses are normal. When checking accommodation, the eyes should converge and the pupils should constrict as the eyes focus on the penlight. The normal result for near vision is 14/14 in each eye. When testing the corneal reflex, touch the eye gently and quickly with a wisp of cotton. The client will react by blinking both eyes. If one or both eyes fail to respond, there could be a problem. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.8: Apply critical thinking in selected simulations related to physical assessment of the eye. Question 32 Type: MCSA The African American middle-aged client has been diagnosed with glaucoma. Which of the following statements by the client indicate that further education is required? 1. “I just thought my pupils were big, I didn’t know it could be associated with glaucoma.” 2. “So, my headaches may be occurring because of the increased pressure within my eyes.” 3. “My race doesn’t have anything to do with this diagnosis.” 4. “Those halos that I see around lights are associated with glaucoma.” Correct Answer: 3

Rationale 1: Glaucoma is a result of restricted fluid flow around the anterior chamber of the eye. The blocked fluid flow results in an increase in the client’s intraocular pressure. Dilated pupils can be found in clients with glaucoma. Rationale 2: Headaches are associated with glaucoma. Rationale 3: African-Americans are more likely to develop glaucoma. Rationale 4: Clients with glaucoma may state that they see halos around lights. Global Rationale: Glaucoma is a result of restricted fluid flow around the anterior chamber of the eye. The blocked fluid flow results in an increase in the client’s intraocular pressure. Dilated pupils can be found in clients with glaucoma. Headaches are associated with glaucoma. African-Americans are more likely to develop glaucoma. Clients with glaucoma may state that they see halos around lights. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.8: Apply critical thinking in selected simulations related to physical assessment of the eye. Question 33 Type: MCSA The nurse is assessing the client’s eyes. Which of the following findings is most consistent with glaucoma? 1. Eyeballs are firm to palpation. 2. Pupils are constricted bilaterally. 3. Central vision is impaired. 4. The client has a history of syphilis. Correct Answer: 1 Rationale 1: A client’s eyeballs that are firm when palpated may have glaucoma. Rationale 2: Dilated, not constricted, pupils are most often associated with glaucoma. Rationale 3: Impaired central vision is associated with macular degeneration. Rationale 4: Clients who have been infected previously with syphilis may develop a condition called Argyll Robertson pupils. This is when the client’s pupils are bilaterally constricted, small, irregular, and nonreactive to light. Global Rationale: A client’s eyeballs that are firm when palpated may have glaucoma. Dilated, not constricted, pupils are most often associated with glaucoma. Impaired central vision is associated with macular degeneration.

Clients who have been infected previously with syphilis may develop a condition called Argyll Robertson pupils. This is when the client’s pupils are bilaterally constricted, small, irregular, and nonreactive to light. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.8: Apply critical thinking in selected simulations related to physical assessment of the eye.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 14 Question 1 Type: HOTSPOT A client is having difficulty maintaining equilibrium. The client is unable to ambulate without pushing a wheelchair or using a walker. Draw an arrow indicating which part of the ear is not functioning adequately.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The ear is divided into three areas: the external ear, the middle ear, and the inner ear. All three are involved in hearing, but only the inner ear is involved in equilibrium. The vestibular apparatus contained in the inner ear must be working adequately for the client to be able to maintain a sense of balance.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat. Question 2 Type: MCSA The client is experiencing the effects of a recent cerebrovascular accident. The client is unable to hear out of the left ear. Which of the following cranial nerves was most likely affected? 1. Cranial nerve I 2. Cranial nerve XII 3. Cranial nerve VIII 4. Cranial nerve VII Correct Answer: 3 Rationale 1: The sense of smell is controlled by cranial nerve I. Rationale 2: Tongue movement is controlled by cranial nerve XII. Rationale 3: Hearing and balance is controlled by cranial nerve VII. Rationale 4: The sense of taste is controlled by cranial nerves VII and IX. Global Rationale: Hearing and balance is controlled by cranial nerve VII. The sense of smell is controlled by cranial nerve I. Tongue movement is controlled by cranial nerve XII. The sense of taste is controlled by cranial nerves VII and IX. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat. Question 3 Type: MCHS The nurse is assessing the client’s vestibule of the oral cavity. The student nurse requests information regarding the vestibule and the mouth. Draw an arrow to the structure that separates the vestibule from the mouth.

Correct Answer: Rationale : 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat. Question 4

Type: MCSA 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. Olfactory cells 2. Columella 3. Turbinates 4. Nares Correct Answer: 3 Rationale 1: The olfactory cells assist the client to smell. Rationale 2: The columella is located at the base of the nose and helps form the nares. Rationale 3: The superior, middle, and inferior turbinates are specifically responsible for warming, moistening, and filtering the air before it enters the trachea and lungs. Rationale 4: The nares are structures that lead into the internal vestibule and nasal cavity. Global Rationale: The superior, middle, and inferior turbinates are specifically responsible for warming, moistening, and filtering the air before it enters the trachea and lungs. The olfactory cells assist the client to smell. The columella is located at the base of the nose and helps form the nares. The nares are structures that lead into the internal vestibule and nasal cavity. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat. Question 5 Type: MCSA Which of the following structures attaches the tongue to the floor of the mouth? 1. Hard palate 2. Papillae 3. Frenulum 4. Alveoli sockets

Correct Answer: 3 Rationale 1: The hard palate is the anterior portion of the roof of the mouth. Rationale 2: The papillae contain the taste buds and assist with moving food within the mouth. The papillae are located on the dorsal surface of the tongue. Rationale 3: The frenulum connects the anterior portion of the tongue to the floor of the mouth. Rationale 4: The alveoli sockets contain the teeth within the mandible and maxilla. Global Rationale: The frenulum connects the anterior portion of the tongue to the floor of the mouth. The hard palate is the anterior portion of the roof of the mouth. The papillae contain the taste buds and assist with moving food within the mouth. The papillae are located on the dorsal surface of the tongue. The alveoli sockets contain the teeth within the mandible and maxilla. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat. Question 6 Type: MCMA The nurse is performing a focused interview with a client who has been cleaning the ears with a cotton-tipped applicator. The nurse should educate the client about which of the following complications that can occur as a result of this practice? Standard Text: Select all that apply. 1. The client has a higher risk of developing otitis externa. 2. The client has a higher risk of developing tophi along the outer rim of the ears. 3. The client could perforate the tympanic membrane. 4. The client could require tympanostomy tubes. 5. The client’s cerumen might become impacted. Correct Answer: 3,5 Rationale 1: The client has a higher risk of developing otitis externa. Otitis externa is an infection of the client’s outer ear. This client does not have an increased risk of developing otitis externa.

Rationale 2: The client has a higher risk of developing tophi along the outer rim of the ears. Tophi are small white nodules that are found on the helix or antihelix. These nodules are a sign of gout and contain uric acid crystals. Rationale 3: The client could perforate the tympanic membrane. This client is at risk for perforating the tympanic membrane with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally. Rationale 4: The client could require tympanostomy tubes. Tympanostomy tubes are placed when clients develop repeated otitis media infections. These tubes help relieve middle ear pressure and allow drainage that occurs as a result of the infection. This client does not require tympanostomy tubes. Rationale 5: The client’s cerumen might become impacted. This client is at risk for impacting the cerumen within the ears with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally. Global Rationale: Otitis externa is an infection of the client’s outer ear. This client does not have an increased risk of developing otitis externa. Tophi are small white nodules that are found on the helix or antihelix. These nodules are a sign of gout and contain uric acid crystals. This client is at risk for perforating the tympanic membrane with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally. Tympanostomy tubes are placed when clients develop repeated otitis media infections. These tubes help relieve middle ear pressure and allow drainage that occurs as a result of the infection. This client does not require tympanostomy tubes. This client is at risk for impacting the cerumen within the ears with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.2: Develop questions to be used when completing the focused interview. Question 7 Type: MCSA The nurse is performing a focused interview with the client. The nurse asks the client if the client has noticed any drainage from the ears, and the client states, “Yes.” Which of the following statements indicate that the client may have developed acute otitis media? 1. “The ear canal itself is really red, raw, and sore.” 2. “I noticed that the drainage looked clear, like water.” 3. “The drainage looks like what is draining from my nose, kind of clear and mucousy.” 4. “It is kind of yellowish-reddish color.” Correct Answer: 4

Rationale 1: When the client complains that the ear canal is inflamed, painful, and with erythema, this indicates that the client may have developed otitis externa. Rationale 2: Clear drainage from the ear may indicate that the client has developed a cerebrospinal fluid leak following trauma. Rationale 3: Serous drainage can indicate that the client has developed drainage from the ears as a result of allergies. Rationale 4: The client with acute otitis media will state that he is experiencing drainage from the ears that is purulent. Reddish-yellow drainage would be classified as purulent. Global Rationale: The client with acute otitis media will state that they are experiencing drainage from the ears that is purulent. Reddish-yellow drainage would be classified as purulent. When the client complains that the ear canal is inflamed, painful, and with erythema, this indicates that the client may have developed otitis externa. Clear drainage from the ear may indicate that the client has developed a cerebrospinal fluid leak following trauma. Serous drainage can indicate that the client has developed drainage from the ears as a result of allergies. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.2: Develop questions to be used when completing the focused interview. Question 8 Type: MCMA The client was given several medications during a recent hospital admission. The client has come to the medical office with complaints of tinnitus and bilateral hearing loss. The nurse understands that which of the following medications are associated with hearing loss or tinnitus? Standard Text: Select all that apply. 1. Streptomycin 2. Steroid inhalers 3. Aspirin 4. Neomycin 5. Acetaminophen Correct Answer: 1,3,4 Rationale 1: Streptomycin. Streptomycin is an antibiotic that can cause hearing loss.

Rationale 2: Steroid inhalers. Steroid inhalers are associated with Candida (yeast infections) in the nasal mucosa. Rationale 3: Aspirin. Aspirin can cause ringing in the ears. Rationale 4: Neomycin. Neomycin is an antibiotic that can cause hearing loss. Rationale 5: Acetaminophen. Acetaminophen is not associated with hearing loss. Global Rationale: Streptomycin is an antibiotic that can cause hearing loss. Steroid inhalers are associated with Candida (yeast infections) in the nasal mucosa. Aspirin can cause ringing in the ears. Neomycin is an antibiotic that can cause hearing loss. Acetaminophen is not associated with hearing loss. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of the ear, nose, mouth, and throat. Question 9 Type: MCSA The client has developed anosmia. The healthcare provider educates the client about the possible causes. The nurse recognizes that which of the following would be an unexpected explanation for this condition? 1. Commonly associated with gingivitis 2. Possibly linked to heredity 3. Related to a diet deficient in zinc 4. An indicator of a neurological problem Correct Answer: 1 Rationale 1: Anosmia is the inability to smell. It is unrelated to gingivitis. Clients with gingivitis often complain of a bad taste in their mouth. Rationale 2: Anosmia is the inability to smell. Anosmia may be related to genetic makeup. Rationale 3: Anosmia is the inability to smell. Anosmia may be related to a diet that is deficient in food containing zinc. Rationale 4: Anosmia is the inability to smell. Anosmia may be related to a neurological disorder.

Global Rationale: Anosmia is the inability to smell. Anosmia may be related to a neurological disorder, genetic makeup, or a diet that is deficient in food containing zinc. It is unrelated to gingivitis. Clients with gingivitis often complain of a bad taste in their mouth. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of the ear, nose, mouth, and throat. Question 10 Type: MCSA 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. Request information from the client regarding any chronic allergies. 2. Test the drainage for glucose. 3. Ask the patient if she has experienced a recent middle ear infection. 4. Irrigate the ear with warm mineral oil, peroxide, and flush with warm water. Correct Answer: 2 Rationale 1: Chronic allergies would not result in clear fluid draining from the client’s ear. However, an acute allergic reaction may result in serous fluid that drains from the client’s ear. Rationale 2: When a client’s ear is draining clear fluid, this might indicate the client has a cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in cerebrospinal fluid. Rationale 3: A recent middle ear infection may result in purulent or bloody drainage from the client’s ear. Rationale 4: The ear should not be irrigated at this time. Irrigation with warm mineral oil, peroxide, and flushing with warm water is often used to remove cerumen. There is nothing to suggest that the client has impacted cerumen. Global Rationale: When a client’s ear is draining clear fluid, this might indicate the client has a cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in cerebrospinal fluid. Chronic allergies would not result in clear fluid draining from the client’s ear. However, an acute allergic reaction may result in serous fluid that drains from the client’s ear. A recent middle ear infection may result in purulent or bloody drainage from the client’s ear. The ear should not be irrigated at this time. Irrigation with warm mineral oil, peroxide, and flushing with warm water is often used to remove cerumen. There is nothing to suggest that the client has impacted cerumen. Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of the ear, nose, mouth, and throat. Question 11 Type: MCSA The nurse is assessing the tympanic membrane of a client and notes the presence of a bluish color. The nurse would suspect which of the following? 1. Acute otitis media 2. Recent head trauma 3. Blocked eustachian tubes 4. History of frequent middle ear infections Correct Answer: 2 Rationale 1: Acute otitis media is associated with a reddish or yellowish tinge on the tympanic membrane. Rationale 2: The presence of a bluish tinge on the tympanic membrane is most likely due to blood in the middle ear and may be indicative of recent head trauma. Rationale 3: A blocked eustachian tube will cause the tympanic membrane to retract. Rationale 4: Previous middle ear infections will result in white patches noted on the tympanic membrane that indicate scarring. Global Rationale: The presence of a bluish tinge on the tympanic membrane is most likely due to blood in the middle ear and may be indicative of recent head trauma. Acute otitis media is associated with a reddish or yellowish tinge on the tympanic membrane. A blocked eustachian tube will cause the tympanic membrane to retract. Previous middle ear infections will result in white patches noted on the tympanic membrane that indicate scarring. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.4: Explain the use of otoscope. Question 12 Type: MCSA

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. Tell the client to move away from the speculum if they experience any pain as the otoscope is advanced. 3. Reinsert the otoscope quickly and press against both sides of the inner auditory canal. 4. Pull the pinna down and back, then reinsert the otoscope. Correct Answer: 1 Rationale 1: To avoid trauma to the ear, the otoscope is to be removed and the pinna should be pulled up and back for better visualization. Rationale 2: The client should be instructed to state any feelings of discomfort or pain but not to pull away because this may result in injury during this examination. Rationale 3: The otoscope should not be inserted quickly and should not be pressed against either side of the inner auditory canal because it would be painful for the client. Rationale 4: Pulling down and back is recommended in children because of the shape of their auditory canal. Global Rationale: To avoid trauma to the ear, the otoscope is to be removed and the pinna should be pulled up and back for better visualization. The client should be instructed to state any feelings of discomfort or pain but not to pull away because this may result in injury during this examination. The otoscope should not be inserted quickly and should not be pressed against either side of the inner auditory canal because it would be painful for the client. Pulling down and back is recommended in children because of the shape of their auditory canal. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.4: Explain the use of otoscope. Question 13 Type: MCMA The nurse is examining a client’s ears and notes that right ear is occluded with wax. The nurse would choose which of the following to remove the earwax? Standard Text: Select all that apply. 1. Irrigation with warm mineral oil, peroxide, followed by warm water 2. A sharp instrument to break up the ear wax

3. Irrigation with a cold solution 4. A cerumen spoon to remove the wax 5. Irrigation with warm sudsy water Correct Answer: 1,4 Rationale 1: Irrigate the ear canal with warm mineral oil, peroxide, followed by warm water. Care must be taken when removing cerumen. Warmed mineral oil and peroxide soften the earwax and the ear can be irrigated with warm water afterwards. Rationale 2: A sharp instrument to break up the ear wax within the ear canal. Sharp instruments should not be placed within the ear canal because it may injure the tympanic membrane. Rationale 3: Irrigate the ear canal with a cold solution. Cold solutions may harden the ear wax, making it more difficult to remove. Rationale 4: A cerumen spoon can be placed in the ear canal to remove the wax. The cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to remove the wax safely without risking injury or perforation of the eardrum. Rationale 5: Irrigate the ear canal with warm sudsy water. Warm, sudsy solutions may irritate the ear canal. Global Rationale: Care must be taken when removing cerumen. Warmed mineral oil and peroxide soften the earwax and the ear can be irrigated with warm water afterwards. Sharp instruments should not be placed within the ear canal because it may injure the tympanic membrane. Cold solutions may harden the ear wax, making it more difficult to remove. The cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to remove the wax safely without risking injury or perforation of the eardrum. Warm, sudsy solutions may irritate the ear canal. Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.4: Explain the use of otoscope. Question 14 Type: MCMA 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? Standard Text: Select all that apply. 1. The nurse notes that the nasal septum has perforated. 2. Temporomandibular joint pain when the client opens and closes the mouth

3. The septum is noted to be very pale in color. 4. Yeast infection of nasal mucosa and in mouth 5. Difficulty swallowing water Correct Answer: 1,3 Rationale 1: The nurse notes that the nasal septum has perforated. When a client is abusing cocaine, the nurse may note that the nasal septum has broken down and has even perforated. Rationale 2: Temporomandibular joint pain when the client opens and closes the mouth. Temporomandibular joint pain could be the result of otitis externa or might indicate temporomandibular joint dysfunction. It is unrelated to cocaine use. Rationale 3: The septum is noted to be very pale in color. When a client is abusing cocaine, the nasal mucosa might appear vasoconstricted and very pale in color. Rationale 4: Yeast infection of nasal mucosa and in mouth. Steroid inhalers can cause growth of Candida in the nose, mouth, or throat. It is unrelated to cocaine use. Rationale 5: Difficulty swallowing water. If the client experiences difficulty in swallowing, this may be due to a neurological or gastrointestinal problem, or it may be related to ill-fitting dentures or malocclusion. Global Rationale: When a client is abusing cocaine, the nurse may note that the nasal septum has broken down and has even perforated. Temporomandibular joint pain could be the result of otitis externa or might indicate temporomandibular joint dysfunction. It is unrelated to cocaine use. When a client is abusing cocaine, the nasal mucosa might appear vasoconstricted and very pale in color. Steroid inhalers can cause growth of Candida in the nose, mouth, or throat. It is unrelated to cocaine use. If the client experiences difficulty in swallowing, this may be due to a neurological or gastrointestinal problem, or it may be related to ill-fitting dentures or malocclusion. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 15 Type: MCSA 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. Correct Answer: 4 Rationale 1: A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely. Rationale 2: Catheter insertion is invasive and increases the client’s risk of developing a urinary tract infection. Rationale 3: Restricting fluid intake is not indicated in this situation. Rationale 4: A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely. Obtaining a bedside commode for the client will help prevent the client from falling while attempting to ambulate independently to and from the bathroom. Global Rationale: A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely. Obtaining a bedside commode for the client will help prevent the client from falling while attempting to ambulate independently to and from the bathroom. Catheter insertion is invasive and increases the client’s risk of developing a urinary tract infection. Restricting fluid intake is not indicated in this situation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15. 5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 16 Type: MCSA A client with a fever is also complaining of difficulty hearing. The nurse realizes this client might be experiencing which of the following disorders? 1. Sinusitis 2. Otitis media 3. Tonsillitis 4. Otitis externa Correct Answer: 2

Rationale 1: Sinusitis is associated with facial pain, inflammation, and nasal discharge. Rationale 2: Fever and hearing loss are clinical manifestations associated with otitis media. Rationale 3: Tonsillitis is associated with reddened, inflamed tonsils and a fever. Rationale 4: Otitis externa is associated with a red, swollen auricle and ear canal. Clients with otitis externa also might have a fever. Global Rationale: Fever and hearing loss are clinical manifestations associated with otitis media. Sinusitis is associated with facial pain, inflammation, and nasal discharge. Tonsillitis is associated with reddened, inflamed tonsils and a fever. Otitis externa is associated with a red, swollen auricle and ear canal. Clients with otitis externa also might have a fever. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 17 Type: MCSA The emergency room triage nurse is assessing a child who has a history of a cough and nasal congestion for the last three days. When assessing patency of the nares, the nurse notes that the child is unable to breathe through the right nostril. The nurse would interpret these assessment findings as which of the following? 1. Produced by severe nasal inflammation or obstruction 2. Normal for a child 3. A result of chronic allergies 4. A result of sinusitis Correct Answer: 1 Rationale 1: If the client cannot breathe through each naris, severe inflammation or an obstruction may be present. Rationale 2: This is not a normal finding in an adult or a child. Rationale 3: If nasal mucosa is pale and boggy or swollen, the client may have chronic allergies. Due to the client’s history, this is an acute problem and not associated with chronic allergies. Rationale 4: The client with sinusitis will have tenderness over sinus cavities.

Global Rationale: If the client cannot breathe through each naris, severe inflammation or an obstruction may be present. This is not a normal finding in an adult or a child. If nasal mucosa is pale and boggy or swollen, the client may have chronic allergies. Due to the client’s history, this is an acute problem and not associated with chronic allergies. The client with sinusitis will have tenderness over sinus cavities. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 18 Type: MCSA A client presents in the healthcare provider’s office with complaints of headache and malaise. The nurse assesses the client and finds that the client has severe pain when the sinuses are palpated. The nurse would suspect which of the following disorders? 1. Sinusitis 2. Mastoiditis 3. Chronic allergies 4. Anemia Correct Answer: 1 Rationale 1: Pain is a common finding during palpation of the sinuses when an infection or inflammation is present in the sinuses. Rationale 2: Mastoiditis is associated with pain and tenderness over the mastoid process, which is located behind the client’s ears. Rationale 3: The client with chronic allergies may have pale, boggy, or swollen nasal mucosa. Rationale 4: Anemia would be associated with pale mucous membranes. Global Rationale: Pain is a common finding during palpation of the sinuses when an infection or inflammation is present in the sinuses. Mastoiditis is associated with pain and tenderness over the mastoid process, which is located behind the client’s ears. The client with chronic allergies may have pale, boggy, or swollen nasal mucosa. Anemia would be associated with pale mucous membranes. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 19 Type: MCSA The nurse is educating a group of teenagers in high school about the risks of chewing tobacco. The nurse would include information about which of the following signs of oral cancer? 1. Bleeding and inflamed gums 2. Smooth and shiny tongue 3. Red, swollen tonsils 4. Ulcerations on the lip or under the tongue Correct Answer: 4 Rationale 1: Bleeding and inflamed gums are associated with gingivitis. Rationale 2: A smooth, shiny tongue is associated with deficiencies of vitamin B and iron. Rationale 3: Red and swollen tonsils are associated with tonsillitis Rationale 4: Oral cancers are most commonly found on the lower lip or the base of the tongue. They do not heal normally. Global Rationale: Oral cancers are most commonly found on the lower lip or the base of the tongue. They do not heal normally. Bleeding and inflamed gums are associated with gingivitis. A smooth, shiny tongue is associated with deficiencies of vitamin B and iron. Red and swollen tonsils are associated with tonsillitis. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 20 Type: MCMA A client arrives in the emergency room with complaints of intermittent nosebleeds for the past two days. Which of the following assessments would be a priority for the nurse is this situation? Standard Text: Select all that apply. 1. Request information from the client regarding increased propensity for bruising or bleeding.

2. Assess the tonsils for redness or swelling. 3. Obtain a blood pressure. 4. Check for deviated septum. 5. Request information from the client to determine if there was any recent thin, watery drainage from the nose. Correct Answer: 1,3,5 Rationale 1: Request information from the client regarding increased propensity for bruising or bleeding. The client may have a blood coagulation disorder that may result in increased bruising or bleeding. This disorder may have produced the episodes of epistaxis. Rationale 2: Assess the tonsils for redness or swelling. Red, swollen tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis. Rationale 3: Obtain a blood pressure. Hypertension is a contributory factor to the occurrence of nosebleeds. The nurse should assess the client’s blood pressure to determine if it is elevated. Rationale 4: Check for deviated septum. A deviated septum is not associated with epistaxis. Rationale 5: Request information from the client to determine if there was any recent thin, watery drainage from the nose. Thin, watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis. Global Rationale: The client may have a blood coagulation disorder that may result in increased bruising or bleeding. This disorder may have produced the episodes of epistaxis. Red, swollen tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis. Hypertension is a contributory factor to the occurrence of nosebleeds. The nurse should assess the client’s blood pressure to determine if it is elevated. A deviated septum is not associated with epistaxis. Thin, watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 21 Type: MCSA The nurse is examining a 14-month-old child when the mother tells the nurse that the child cries frequently, has a fever, and is pulling at both ears. The nurse suspects the child has which of the following disorders from this assessment data? 1. Otitis media

2. Otitis externa 3. Hemotympanum 4. Tophi Correct Answer: 1 Rationale 1: The auditory canal of infants is shorter and has an upward curve that persists until about the age of 3. In addition, their auditory tube is more horizontal than the adult, which leads to easier migration of organisms from the throat to the middle ear. Infants and children with otitis media often display the behavior of pulling at their ears. Rationale 2: Otitis externa is an infection of the external auditory canal manifested by red, swollen ear canal, fever, and purulent drainage. Rationale 3: Hemotympanum is a bluish tinge of the tympanic membrane indicating the presence of blood in the middle ear. It is usually associated with head trauma. Rationale 4: Tophi are small white nodules on the helix or antihelix. These nodules contain uric acid crystals and are a sign of gout. Global Rationale: The auditory canal of infants is shorter and has an upward curve that persists until about the age of 3. In addition, their auditory tube is more horizontal than the adult, which leads to easier migration of organisms from the throat to the middle ear. Infants and children with otitis media often display the behavior of pulling at their ears. Otitis externa is an infection of the external auditory canal manifested by red, swollen ear canal, fever, and purulent drainage. Hemotympanum is a bluish tinge of the tympanic membrane indicating the presence of blood in the middle ear. It is usually associated with head trauma. Tophi are small white nodules on the helix or antihelix. These nodules contain uric acid crystals and are a sign of gout. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 22 Type: MCSA The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Based on this finding, the nurse would implement which of the following actions first? 1. Administer IV fluids. 2. Provide oral hygiene. 3. Administer oxygen.

4. Provide a warm drink. Correct Answer: 3 Rationale 1: There is no indication the client has an electrolyte or fluid imbalance at this time, making the administration of IV fluids inappropriate at this time. Rationale 2: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. Providing oral hygiene is not an appropriate intervention because it will not increase the client’s oxygenation levels. Rationale 3: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. The nurse should apply oxygen for the client. Rationale 4: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. Providing a warm drink will not correct the client’s oxygenation problem. Global Rationale: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. The nurse should apply oxygen for the client. There is no indication the client has an electrolyte or fluid imbalance at this time, making the administration of IV fluids inappropriate at this time. Providing oral hygiene is not an appropriate intervention because it will not increase the client’s oxygenation levels. Providing a warm drink will not correct the client’s oxygenation problem. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 23 Type: MCSA The nurse is assessing the client’s nasal mucosa and notes the presence of a thin, watery discharge. The client complains of sneezing and nasal congestion. The nurse would suspect which of the following in this situation? 1. Rhinitis 2. Perforated septum 3. Previous epistaxis 4. Nasal polyps Correct Answer: 1 Rationale 1: These clinical manifestations are associated with rhinitis. Rhinitis is inflammation of the nasal mucosa due to a viral infection or allergy.

Rationale 2: A perforated septum is a hole in the septum caused by chronic infection, trauma, or sniffing cocaine. It can be detected by shining a penlight through the naris on the other side. Rationale 3: With a history of epistaxis, the nurse would note that there is old dried blood on the nasal mucosa. Rationale 4: Nasal polyps are pale, round, firm, nonpainful overgrowth of nasal mucosa. Global Rationale: These clinical manifestations are associated with rhinitis. Rhinitis is inflammation of the nasal mucosa due to a viral infection or allergy. A perforated septum is a hole in the septum caused by chronic infection, trauma, or sniffing cocaine. It can be detected by shining a penlight through the naris on the other side. With a history of epistaxis, the nurse would note that there is old dried blood on the nasal mucosa. Nasal polyps are pale, round, firm, nonpainful overgrowth of nasal mucosa. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 24 Type: MCSA The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the tongue. Which of the following questions would be appropriate for the nurse to include when obtaining further assessment data? 1. “Have you eaten licorice lately?” 2. “How often do you brush your tongue?” 3. “Have you recently taken antibiotics?” 4. “Have you ever had this happen before?” Correct Answer: 3 Rationale 1: This finding is unrelated to food intake such as eating licorice. Rationale 2: This finding is not related to poor oral hygiene practices. Rationale 3: The presence of a black, furry-looking coating on the tongue is usually related to an overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use. Rationale 4: It may helpful for the nurse to determine if the condition has occurred previously but it is not the most important question. The nurse should question the client regarding recent antibiotic use. Global Rationale: The presence of a black, furry-looking coating on the tongue is usually related to an overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use. This finding is not related to poor

oral hygiene practices. It is unrelated to food intake such as eating licorice. It may helpful for the nurse to determine if the condition has occurred previously but it is not the most important question. The nurse should question the client regarding recent antibiotic use. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 25 Type: MCSA An elderly client says, “I can’t seem to hear as well as I could when I was younger.” The nurse suspects this client is experiencing which of the following disorders? 1. Presbycusis 2. Mastoiditis 3. Otitis media 4. Otitis externa Correct Answer: 1 Rationale 1: Age-related changes include loss of low- and high-frequency hearing, also known as presbycusis. Rationale 2: Mastoiditis is a complication of either a middle ear infection or a throat infection. The client would complain of pain or tenderness behind the ear. Rationale 3: Otitis media is an infection of the middle ear producing a red, bulging eardrum, fever, and hearing loss. Rationale 4: Otitis externa is an infection of the outer ear, often called “swimmer’s ear.” Otitis externa causes redness and swelling of the auricle and ear canal. Global Rationale: Age-related changes include loss of low- and high-frequency hearing, also known as presbycusis. Mastoiditis is a complication of either a middle ear infection or a throat infection. The client would complain of pain or tenderness behind the ear. Otitis media is an infection of the middle ear producing a red, bulging eardrum, fever, and hearing loss. Otitis externa is an infection of the outer ear, often called “swimmer’s ear.” Otitis externa causes redness and swelling of the auricle and ear canal. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat. Question 26 Type: MCSA The nurse is assessing the oral mucosa of a pregnant female and notes enlargement of the gums. The client states that regular oral hygiene is performed and that she does not understand why this has occurred. Which of the following is the nurse’s best response? 1. “You may have oral cancer.” 2. “You are experiencing a normal change during pregnancy.” 3. “You may have leukoplakia.” 4. “You need to decrease the frequency of your oral hygiene.” Correct Answer: 2 Rationale 1: Early signs of oral cancer are manifested by ulcers in the lower lip and under the tongue that do not heal normally. Rationale 2: Gingival hyperplasia (enlargement of the gums) is a normal physiologic change associated with pregnancy. It is also seen in clients with leukemia and prolonged use of Dilantin. Rationale 3: Leukoplakia is a whitish thickening of the mucous membrane in the mouth or tongue. It cannot be scraped off. It is most often associated with heavy smoking or drinking, and it can be a precancerous condition. Rationale 4: Advanced gingivitis and poor dental hygiene are manifested by swollen red gums that will bleed when brushed, and will show separation of the gum from the tooth. Global Rationale: Gingival hyperplasia (enlargement of the gums) is a normal physiologic change associated with pregnancy. It is also seen in clients with leukemia and prolonged use of Dilantin. Early signs of oral cancer are manifested by ulcers in the lower lip and under the tongue that do not heal normally. Leukoplakia is a whitish thickening of the mucous membrane in the mouth or tongue. It cannot be scraped off. It is most often associated with heavy smoking or drinking, and it can be a precancerous condition. Advanced gingivitis and poor dental hygiene are manifested by swollen red gums that will bleed when brushed, and will show separation of the gum from the tooth. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 27

Type: MCMA 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? Standard Text: Select all that apply. 1. “The baby’s last bottle before bedtime should only contain water.” 2. “It is important not to prop the baby’s bottle during feeding.” 3. “You must rinse the baby’s mouth right after the baby falls asleep.” 4. “You must perform oral hygiene more frequently throughout the day.” 5. “The last bottle of the evening should not be given just before the baby goes to sleep.” Correct Answer: 2,5 Rationale 1: “The baby’s last bottle before bedtime should only contain water.” Milk should not be replaced with water because the baby may not receive enough nutrition. Bottles should not be given just before bedtime. Rationale 2: “It is important not to prop the baby’s bottle during feeding.” A primary source of ear infection in infants and small children is the practice of propping the bottle with milk or juice. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory tube. Rationale 3: “You must rinse the baby’s mouth right after the baby falls asleep.” This would not be appropriate and might be dangerous for the baby. Providing oral hygiene for children immediately before bedtime might be helpful to help reduce the risk of ear infections. Rationale 4: “You must perform oral hygiene more frequently throughout the day.” Increasing the oral hygiene frequency throughout the day will not improve this situation if bottle propping is occurring or if the baby is given a bottle immediately prior to bedtime. Rationale 5: “The last bottle of the evening should not be given just before the baby goes to sleep.” A major source of ear infection in infants and small children is the practice of giving the baby a bottle at bedtime. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory tube. Global Rationale: Milk should not be replaced with water because the baby may not receive enough nutrition. Bottles should not be given just before bedtime. A primary source of ear infection in infants and small children is the practice of propping the bottle with milk or juice. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory tube. This would not be appropriate and might be dangerous for the baby. Providing oral hygiene for children immediately before bedtime might be helpful to help reduce the risk of ear infections. Increasing the oral hygiene frequency throughout the day will not improve this situation if bottle propping is occurring or if the baby is given a bottle immediately prior to bedtime. A major source of ear infection in infants

and small children is the practice of giving the baby a bottle at bedtime. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory tube. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 28 Type: MCSA The nurse is assessing the ears, nose and mouth of an Asian client with a student nurse. Which of the following statements made by the nurse to the student nurse about cultural differences is accurate? 1. “Asians are more likely to experience greater difficulty with otitis media than people from other cultures. “ 2. “Sometimes in Asians and Native Americans, their ear wax looks dry and dark.” 3. “Asians have a higher risk of having issues associated with cleft lips and cleft palates.” 4. “Asians have a high incidence of tooth decay.” Correct Answer: 2 Rationale 1: Asians do not have a tendency to develop otitis media more than other cultures. Rationale 2: Cerumen appears dry and gray to brown in Asians and Native Americans. Cerumen found in Caucasians and African Americans looks moist and yellow-orange in color. Rationale 3: Cleft lip and palate occur with greatest frequency in Asians and least often in African Americans. Rationale 4: Caucasians have the highest incidence of tooth decay. Global Rationale: Cerumen appears dry and gray to brown in Asians and Native Americans. Cerumen found in Caucasians and African Americans looks moist and yellow-orange in color. Asians do not have a tendency to develop otitis media more than other cultures. Cleft lip and palate occur with greatest frequency in Asians and least often in African Americans. Caucasians have the highest incidence of tooth decay. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 29 Type: MCSA The nurse is assessing several children in a pediatric clinic. Which of the following children might be experiencing delayed development? 1. The 6-year-old child has lost 2 deciduous teeth. 2. The 26-month-old child has one baby tooth. 3. The 4-month-old infant is drooling. 4. The 2-month-old infant’s salivary glands are not producing saliva. Correct Answer: 2 Rationale 1: Eruption of permanent teeth begins at around age 6 and continues through adolescence. Rationale 2: Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26-month-old child might be expected to have more than one deciduous tooth. Rationale 3: Drooling of saliva occurs for several months after saliva is produced (3 months old) until swallowing saliva is learned. Rationale 4: Salivation begins at 3 months of age. Global Rationale: Eruption of permanent teeth begins at around age 6 and continues through adolescence. Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26-month-old child might be expected to have more than one deciduous tooth. Drooling of saliva occurs for several months after saliva is produced (3 months old) until swallowing saliva is learned. Salivation begins at 3 months of age. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 30 Type: MCMA During the focused interview, the client provides information to the nurse regarding her daughter’s recent diagnosis with cancer. The client is exhibiting clinical manifestations associated with anxiety. During the physical assessment, which of the following findings might be expected? Standard Text: Select all that apply. 1. The client complains of pain when the tragus is gently manipulated.

2. The client has several small ulcers on her lip. 3. Pale nasal mucosa 4. Small sores are noted within the mouth. 5. Perforated nasal septum Correct Answer: 1,2,4 Rationale 1: The client complains of pain when the tragus is gently manipulated. Pain that occurs with manipulation of the tragus may accompany temporomandibular joint dysfunction that may be associated with jaw clenching. Jaw clenching can accompany psychological stress. Rationale 2: The client has several small ulcers on her lip. Clients who are under a great deal of stress might bite their lips. Rationale 3: Pale nasal mucosa. Pale nasal mucosa is associated with cocaine use, infection, hypoxia, and allergies. Rationale 4: Small sores are noted within the mouth. Clients who are under a great deal of stress might present with ulcers in their mouth. Rationale 5: Perforated nasal septum. A perforated nasal septum is associated with cocaine use. Global Rationale: Pain that occurs with manipulation of the tragus may accompany temporomandibular joint dysfunction that may be associated with jaw clenching. Jaw clenching can accompany psychological stress. Clients who are under a great deal of stress might bite their lips. Pale nasal mucosa is associated with cocaine use, infection, hypoxia, and allergies. Clients who are under a great deal of stress might present with ulcers in their mouth. A perforated nasal septum is associated with cocaine use. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 31 Type: MCMA The nurse is conducting a hearing assessment on an older adult client with impacted cerumen noted in the right ear canal. When performing the Weber test, the nurse would expect to learn which of the following? Standard Text: Select all that apply. 1. Air conduction is longer than bone conduction.

2. Bone conduction is longer than air conduction. 3. Sound lateralized to the right ear. 4. The client is unable to maintain balance while standing. 5. The 4 year old placed a pea into his nose during lunch. Correct Answer: 3 Rationale 1: The Rinne test, not the Weber test, compares air and bone conduction. Rationale 2: The Rinne test, not the Weber test, compares air and bone conduction. Rationale 3: The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. With impacted cerumen, an ear infection, or a perforated tympanic membrane, the sound will lateralize to the affected ear during the Weber test. Rationale 4: The Romberg test is used to determine equilibrium and the client’s ability to maintain balance while standing. Rationale 5: The 4 year old placed a pea into his nose during lunch. Children are more likely to introduce foreign objects into their mouth and nose. This behavior is not associated with gum or oral mucosa problems. Global Rationale: The Rinne test compares air and bone conduction. Normally, the sound is heard twice as long by air conduction than by bone conduction after bone conduction stops. The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. With impacted cerumen, an ear infection, or a perforated tympanic membrane, the sound will lateralize to the affected ear during the Weber test. The Romberg test is used to determine equilibrium and the client’s ability to maintain balance while standing. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.8: Apply critical thinking in selected simulations related to physical assessment of the structures of the ear, nose, mouth, and throat. Question 32 Type: MCSA The nurse is performing the Weber test. The nurse documents that the sound lateralized to the client’s right ear. The student nurse observing the assessment asks the nurse about the meaning of this documentation. Which of the following is the nurse’s best response? 1. “This just means that I am unable to visualize the client’s tympanic membrane.” 2. “It refers to the client’s inability to hear whispered statements.”

3. “The client is able to hear bone-conducted sound longer than air conducted sound.” 4. “The client is able to hear bone-conducted sound better through the impaired ear.” Correct Answer: 4 Rationale 1: While it is possible that the nurse is unable to visualize the tympanic membrane due to cerumen and this is the reason for sound lateralizing to one ear during the Weber test, this is not the nurse’s best response. Rationale 2: The client’s ability to hear whispered statements at 1–2 feet away is assessed during the whisper test. Rationale 3: The Weber test is performed to determine if during bone conduction, with the use of a tuning fork, the client hears the sound in one ear better than the other. If there is impaired conduction in one ear, the sound will lateralize to that ear during the Weber test. Rationale 4: The Rinne test compares air and bone conduction of sound with the use of a tuning fork. Global Rationale: While it is possible that the nurse is unable to visualize the tympanic membrane due to cerumen and this is the reason for sound lateralizing to one ear during the Weber test, this is not the nurse’s best response. The Weber test is performed to determine if during bone conduction, with the use of a tuning fork, the client hears the sound in one ear better than the other. If there is impaired conduction in one ear, the sound will lateralize to that ear during the Weber test. The client’s ability to hear whispered statements at 1–2 feet away is assessed during the whisper test. The Rinne test compares air and bone conduction of sound with the use of a tuning fork. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.8: Apply critical thinking in selected simulations related to physical assessment of the structures of the ear, nose, mouth, and throat. Question 33 Type: MCSA The client admits to cleaning his ears with a cotton-tipped applicator. As a consequence, the client has developed impacted cerumen and unilateral hearing loss. As the nurse prepares the client’s plan of care, which of the following nursing diagnoses is most applicable? 1. Acute pain 2. Knowledge deficit 3. Acute confusion 4. Unilateral neglect Correct Answer: 2

Rationale 1: Acute pain would be appropriate if the client had perforated the tympanic membrane with the cotton-tipped applicator. However, there are no data to suggest this. Rationale 2: Of the choices, the best nursing diagnosis for this client is knowledge deficit regarding how to adequately care for his ears. Another possible nursing diagnosis that would be applicable for this client is disturbed sensory perception because he will be unable to hear well out of the ear that is impacted with cerumen. Rationale 3: Acute confusion is not an appropriate nursing diagnosis. This client will not develop confusion as a result of unilateral hearing loss. Rationale 4: The client will not neglect one side as a result of unilateral hearing loss. Global Rationale: Of the choices, the best nursing diagnosis for this client is knowledge deficit regarding how to adequately care for his ears. Another possible nursing diagnosis that would be applicable for this client is disturbed sensory perception because he will be unable to hear well out of the ear that is impacted with cerumen. Acute pain would be appropriate if the client had perforated the tympanic membrane with the cotton-tipped applicator. However, there are no data to suggest this. Acute confusion is not an appropriate nursing diagnosis. This client will not develop confusion as a result of unilateral hearing loss. The client will not neglect one side as a result of unilateral hearing loss. Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.8: Apply critical thinking in selected simulations related to physical assessment of the structures of the ear, nose, mouth, and throat.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 15 Question 1 Type: HOTSPOT The client aspirated a pea during a meal. The healthcare provider noted that the pea was in the bronchus. Draw an arrow to the most likely site of the pea.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.1: Identify the anatomy and physiology of the respiratory system.

Question 2 Type: MCSA 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? 1. 1 2. 5 3. 9 4. 12 Correct Answer: 4 Rationale 1: Anteriorly, the first seven pairs of ribs articulate directly to the sternum. Rationale 2: Anteriorly, the first seven pairs of ribs articulate directly to the sternum. Rationale 3: The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7. Rationale 4: The rib pairs of 11 and 12 are free floating and do not articulate anteriorly. Global Rationale: The 12 pairs of ribs circle the body, form the lateral aspects of the thorax, and are attached to the vertebrae and sternum. Anteriorly, the first seven pairs of ribs articulate directly to the sternum. The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7, whereas the pairs of 11 and 12 are free floating and do not articulate anteriorly. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1: Identify the anatomy and physiology of the respiratory system. Question 3 Type: HOTSPOT Draw an arrow that points to the right anterior axillary line (AAL).

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib. Global Rationale: Cognitive Level: Remembering

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory system. Question 4 Type: MCSA The nurse wants to assess the apex of a client’s right lung. Which of the following locations should the nurse place the stethoscope to assess this area on the client? 1. Intercostal space 6th rib near the sternum 2. Intercostal space 4th rib near the axillary line 3. Below the scapula 4. Near the right clavicle Correct Answer: 4 Rationale 1: The apex of each lung is slightly superior to the inner third of the clavicle. Rationale 2: The apex of each lung is slightly superior to the inner third of the clavicle. Rationale 3: The apex of each lung is slightly superior to the inner third of the clavicle. Rationale 4: The apex of each lung is slightly superior to the inner third of the clavicle. Global Rationale: The apex of each lung is slightly superior to the inner third of the clavicle whereas the base of each lung rests on the diaphragm. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory system. Question 5 Type: MCSA During the respiratory assessment of a client the nurse wishes to locate the angle of Louis. This structure can be identified by using which of the following landmarks? 1. Clavicle 2. Sternum

3. First rib 4. Vertebral column Correct Answer: 2 Rationale 1: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum. Rationale 2: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum. Rationale 3: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum. Rationale 4: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum. Global Rationale: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory system. Question 6 Type: MCSA While assessing the client, the nurse notes that the client has a moist cough. The nurse would include which of the following questions in the focused interview? 1. “Have you been losing weight?” 2. “How long have you been sick?” 3. “Are you wheezing?” 4. “Are you coughing up any mucus or phlegm?” Correct Answer: 4 Rationale 1: At this point, the client should not be questioned about weight loss. Rationale 2: The client may not necessarily be “sick.”

Rationale 3: The client should be questioned about the cough during the focused interview and not about wheezing. Rationale 4: The nurse must determine if the cough is productive or nonproductive. A moist cough is often associated with lung infections. The color and odor of any mucus or phlegm (sputum) is associated with specific diseases or problems Global Rationale: The nurse must determine if the cough is productive or nonproductive. A moist cough is often associated with lung infections. The color and odor of any mucus or phlegm (sputum) is associated with specific diseases or problems. At this point, the client should not be questioned about weight loss. The client may not necessarily be “sick.” The client should be questioned about the cough during the focused interview and not about wheezing. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3: Develop questions to be used when completing the focused interview. Question 7 Type: MCSA 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 place a hand on the client’s chest to count respirations accurately. 2. The nurse should inform the client that the nurse is counting the client’s respirations. 3. The nurse should count only the respirations that are audible. 4. The nurse should count the respirations in an unobtrusive manner without informing the client. Correct Answer: 4 Rationale 1: Though laying a hand on the client’s chest allows the nurse to feel the rise and fall of the chest, this may be considered an intrusive move and might increase the client’s level of anxiety, which may affect the respiratory rate. Rationale 2: The nurse should not inform the client about this portion of the assessment. Rationale 3: Not all clients have audible respiratory cycles, and this would not be an effective method for accuracy. Rationale 4: If a client knows his respirations are being counted, it may alter the normal breathing pattern. Global Rationale: If a client knows his respirations are being counted, it may alter the normal breathing pattern. Though laying a hand on the client’s chest allows the nurse to feel the rise and fall of the chest, this may be

considered an intrusive move and might increase the client’s level of anxiety, which may affect the respiratory rate. The nurse should not inform the client about this portion of the assessment. Not all clients have audible respiratory cycles, and this would not be an effective method for accuracy. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.4: Explain client preparation for assessment of the respiratory system. Question 8 Type: SEQ The nurse is preparing to assess the client’s respiratory system. Rank in order according to how the nurse should proceed. Standard Text: Click and drag the options below to move them up or down. Choice 1. Auscultation Choice 2. Inspection Choice 3. Percussion Choice 4. Client survey Choice 5. Palpation Correct Answer: 4,2,5,3,1 Rationale 1: The fifth step in physical assessment of the respiratory system is auscultation. Rationale 2: The second step of respiratory assessment is inspection of the anterior and posterior thorax. Rationale 3: The fourth step in physical assessment of the respiratory system is percussion of the anterior and posterior thorax. Rationale 4: The first step in any physical assessment is the client survey. Rationale 5: The third step in respiratory assessment is palpation of the structures of the anterior and posterior thorax. Global Rationale: The physical assessment of the respiratory system follows an organized pattern. It begins with the client survey, then inspection of the anterior and posterior thorax. The assessment ends with palpation, percussion, and auscultation of the anterior thorax. Cognitive Level: Analyzing Client Need: Safe Effective Care Environment

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory system. Question 9 Type: HOTSPOT Draw an arrow to the area where tracheal breath sounds can be auscultated.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : Tracheal breath sounds are heard over the trachea when the client inhales and exhales. They are harsh and high-pitched. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory system. Question 10 Type: MCSA The client was brought to the Emergency Department. The nurse administered a breathing treatment for the client earlier. The nurse is preparing the client for a procedure. The nurse notes that the client is breathing in a shallow manner and the client’s hands are trembling. Which of the following actions will help decrease the client’s level of anxiety? 1. The nurse should explain all procedures in a calm and reassuring voice. 2. Request the immediate presence of the healthcare provider. 3. Provide oxygen for the client. 4. Postpone the procedure.

Correct Answer: 1 Rationale 1: Clients experiencing anxiety may demonstrate trembling hands and a shallow breathing pattern. Certain drugs, such as bronchodilators, are used in the treatment of respiratory conditions and may cause the hands to tremble visibly. The nurse should not confuse this sign with nervousness. Even mild respiratory distress is frightening for the client and family. Proceeding in a calm and reassuring manner helps reduce the client’s fear. Rationale 2: At this time, there is no reason to request the presence of the healthcare provider. Rationale 3: There is not enough information about the information to assume the client requires oxygen. Rationale 4: The nurse does not need to postpone the procedure. Global Rationale: Clients experiencing anxiety may demonstrate trembling hands and a shallow breathing pattern. Certain drugs, such as bronchodilators, are used in the treatment of respiratory conditions and may cause the hands to tremble visibly. The nurse should not confuse this sign with nervousness. Even mild respiratory distress is frightening for the client and family. Proceeding in a calm and reassuring manner helps reduce the client’s fear. At this time, there is no reason to request the presence of the healthcare provider. There is not enough information about the information to assume the client requires oxygen. The nurse does not need to postpone the procedure. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory system. Question 11 Type: MCSA 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 up one side of the thorax, then up the other. 3. First down one side of the thorax, then down the other. 4. From side to side. Correct Answer: 4 Rationale 1: The usual movement is from apices to the bases. Rationale 2: Auscultation should follow the same pattern as for percussion, from side to side, because comparison of sounds is an important step in respiratory assessment.

Rationale 3: Auscultation should follow the same pattern as for percussion, from side to side, because comparison of sounds is an important step in respiratory assessment. Rationale 4: Auscultation should follow the same pattern as for percussion, from side to side, because comparison of sounds is an important step in respiratory assessment. Global Rationale: Auscultation should follow the same pattern as for percussion, from side to side, because comparison of sounds is an important step in respiratory assessment. Auscultate through the entire respiratory cycle, inspiration and expiration. The student nurse should ask the client to breathe deeply through the mouth each time the stethoscope is placed on the chest. The usual movement is from apices to the bases. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory system. Question 12 Type: MCMA The nurse is preparing to auscultate a client’s lungs. Which of the following breath sounds would be considered abnormal? Standard Text: Select all that apply. 1. Crackles 2. Vesicular 3. Bronchovesicular 4. Wheezes 5. Bronchial Correct Answer: 1,4 Rationale 1: Crackles. Crackles are adventitious, or abnormal, lung sounds produced by collapsed or fluid-filled alveoli. Rationale 2: Vesicular. Vesicular sounds are normal and can be heard over the apices. Rationale 3: Bronchovesicular. Bronchovesicular sounds are normal sounds that can be auscultated over the bronchi. Rationale 4: Wheezes. Wheezes are the result of blocked airflow as in asthma, infection, or due to a foreign body.

Rationale 5: Bronchial. Bronchial sounds are normal and can be heard to the right and left of the trachea over the bronchi. Global Rationale: Crackles are adventitious, or abnormal, lung sounds produced by collapsed or fluid-filled alveoli. Vesicular sounds are normal and can be heard over the apices. Bronchovesicular sounds are normal sounds that can be auscultated over the bronchi. Wheezes are the result of blocked airflow as in asthma, infection, or due to a foreign body. Bronchial sounds are normal and can be heard to the right and left of the trachea over the bronchi. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 13 Type: MCSA The nurse is assessing the client. The nurse hears low-pitched, continuous respiratory sounds that have a snoring quality while auscultating the client’s lungs. The nurse would correctly document these findings as which of the following? 1. Rales 2. Crackles 3. Rhonchi 4. Wheezes Correct Answer: 3 Rationale 1: Rales are intermittent, non-musical brief sounds. Rationale 2: Coarser and louder rales are referred to as crackles. Rationale 3: There are two types of continuous respiratory sounds that may be heard during the respiratory cycle. Rhonchi are low-pitched and have a snoring quality. Rationale 4: There are two types of continuous respiratory sounds that may be heard during the respiratory cycle. Wheezes are high-pitched with a shrill quality. Global Rationale: There are two types of continuous respiratory sounds that may be heard during the respiratory cycle. Rhonchi are low-pitched and have a snoring quality, while wheezes are high-pitched with a shrill quality. Rales are intermittent, nonmusical, brief sounds. Coarser and louder rales are referred to as crackles. Cognitive Level: Understanding Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment Question 14 Type: MCMA While palpating respiratory expansion on a client in the emergency room the nurse notes movement on only one side of the chest. Which of the following conditions may produce this finding? Standard Text: Select all that apply. 1. Atelectasis 2. Chronic bronchitis 3. Lobar pneumonia 4. Pleural effusion 5. Congestive heart failure Correct Answer: 1,3,4 Rationale 1: Atelectasis. Atelectasis is a condition in which there is an obstruction of airflow. Lung tissue may collapse from airway obstruction, such as a mucous plug, lack of surfactant, or a compressed chest wall. Atelectasis will result in decreased lung expansion on the client’s affected side. Rationale 2: Chronic bronchitis. Chronic inflammation of the tracheobronchial tree leads to increased mucous production and blocked airways. It does not result in decreased lung expansion on one side. Rationale 3: Lobar pneumonia. It is due to an infection that causes fluid, bacteria, and cellular debris to fill the alveoli. It may result in decreased lung expansion on the client’s affected side. Rationale 4: Pleural effusion. This condition refers to fluid accumulating in the pleural space. It may result in decreased lung expansion on the client’s affected side. Rationale 5: Congestive heart failure. This is when increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause edema of the bronchial mucosa. It does not result in decreased lung expansion on one side. Global Rationale: Atelectasis is a condition in which there is an obstruction of airflow. Lung tissue may collapse from airway obstruction, such as a mucous plug, lack of surfactant, or a compressed chest wall. Atelectasis will result in decreased lung expansion on the client’s affected side. Chronic bronchitis results in chronic inflammation of the tracheobronchial tree, which leads to increased mucous production and blocked airways. It does not result in decreased lung expansion on one side. Lobar pneumonia is due to an infection that causes fluid, bacteria, and cellular debris to fill the alveoli. It may result in decreased lung expansion on the client’s affected side. Pleural effusion refers to fluid accumulating in the pleural space. It may result in decreased lung expansion on the client’s

affected side. Congestive heart failure occurs when increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause edema of the bronchial mucosa. It does not result in decreased lung expansion on one side. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment Question 15 Type: MCMA The nurse is assessing a client with a severe left pleural effusion. Which of the following findings are expected? Standard Text: Select all that apply. 1. Absent breath sounds on the left side 2. Tracheal shift to the right 3. Hyperresonance upon percussion. 4. Bronchial breath sounds of the right side 5. Pleural friction rub auscultated. Correct Answer: 1,2,5 Rationale 1: Absent breath sounds on the left side. In this condition, fluid accumulates in the pleural space and may result in absent breath sounds on the affected side. Rationale 2: Tracheal shift to the right. In this condition, fluid accumulates in the pleural space. The trachea may shift to the unaffected side. Rationale 3: Hyperresonance upon percussion. The trapping of air in the alveoli will produce a sound of hyperresonance upon percussion. This is not a typical finding in someone who has been diagnosed with a pleural effusion. Rationale 4: Bronchial breath sounds of the right side. This is not a typical finding in someone who has been diagnosed with a pleural effusion. Rationale 5: Pleural friction rub auscultated. In this condition, fluid accumulates in the pleural space, and a pleural friction rub may be present during auscultation. Global Rationale: In this condition, fluid accumulates in the pleural space and may result in absent breath sounds on the affected side, a tracheal shift to the unaffected side, and a pleural friction rub. The trapping of air in the alveoli will produce a sound of hyperresonance upon percussion. This is not a typical finding in someone who has

been diagnosed with a pleural effusion. Bronchial breath sounds of the right side is not a typical finding in someone who has been diagnosed with a pleural effusion. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 16 Type: MCSA The nurse is assessing the client’s respiratory pattern and notes periods of deep breathing alternating with periods of apnea. Which of the following terms would the nurse use to document this finding? 1. Tachypnea 2. Obstructive breathing 3. Hypoventilation 4. Cheyne-Stokes Correct Answer: 4 Rationale 1: The client who has tachypnea exhibits rapid and shallow respirations. Rationale 2: Clients with obstructive breathing have prolonged expirations. Rationale 3: Hypoventilation is irregular and shallow breathing. Rationale 4: The breathing described is a Cheyne-Stokes pattern. Global Rationale: The breathing described is a Cheyne-Stokes pattern. The client who has tachypnea exhibits rapid and shallow respirations. Clients with obstructive breathing have prolonged expirations. Hypoventilation is irregular and shallow breathing. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 17 Type: MCSA During the assessment of a client’s voice sounds, the nurse hears louder sounds over the client’s right lower lobe. This finding would be consistent with:

1. Atelectasis. 2. Lobar pneumonia. 3. Asthma. 4. Pleural effusion. Correct Answer: 2 Rationale 1: Voice sounds are decreased or absent over areas of atelectasis. Rationale 2: Voice sounds are increased and clearer over areas affected by lobar pneumonia. Rationale 3: Voice sounds are decreased or absent over areas of asthma. Rationale 4: Voice sounds are decreased or absent over areas of pleural effusion. Global Rationale: Voice sounds are decreased or absent over areas of atelectasis, asthma, pleural effusion, and pneumothorax. Voice sounds are increased and clearer over areas affected by lobar pneumonia. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 18 Type: MCSA The nurse percusses the lungs and determines that there is an area of hyperresonance. This finding is consistent with which of the following conditions? 1. Pneumonia 2. Atelectasis 3. Pneumothorax 4. Pleural effusion Correct Answer: 3 Rationale 1: When percussing a client with pneumonia the nurse would hear dullness over the affected area. Rationale 2: When percussing a client with atelectasis the nurse would hear dullness over the affected area.

Rationale 3: Hyperresonance can be auscultated in clients with conditions that involve overinflated lungs such as emphysema and with pneumothorax. Rationale 4: When percussing a client with a pleural effusion, the nurse would hear dullness over the affected area. Global Rationale: Hyperresonance can be auscultated in clients with conditions that involve overinflated lungs such as emphysema and with pneumothorax. When percussing a client with pneumonia, atelectasis, or a pleural effusion, the nurse would hear dullness over the affected area. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 19 Type: MCSA While the client sleeps, the nurse notes that the client’s respirations periodically stop. This finding would be documented as: 1. Tachypnea. 2. Bradypnea. 3. Apnea. 4. Atelectasis. Correct Answer: 3 Rationale 1: Tachypnea is a term used to describe rapid, shallow respirations that are greater than 24 per minute. Rationale 2: Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute. Rationale 3: Apnea is the cessation of breathing lasting from a few seconds to a few minutes. Rationale 4: The findings do not indicate atelectasis, which is alveolar or lung collapse. Global Rationale: Apnea is the cessation of breathing lasting from a few seconds to a few minutes. Tachypnea is a term used to describe rapid, shallow respirations that are greater than 24 per minute. Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute. The findings do not indicate atelectasis, which is alveolar or lung collapse. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 20 Type: MCSA 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. Fatigued. 2. Anxious. 3. Normal. 4. Bored. Correct Answer: 2 Rationale 1: Fatigue does not usually result in tachypnea. Rationale 2: Tachypnea, or rapid, shallow respirations, are greater than 24 per minute and may be caused by fever, fear, exercise, respiratory insufficiency, pleuritic pain, alkalosis, or pneumonia. Rationale 3: Normal respirations are even and regular. A normal respiratory rate is over 10 and under 24 respirations per minute. Rationale 4: The bored client may exhibit a slower respiratory rate. Global Rationale: Tachypnea, or rapid, shallow respirations, are greater than 24 per minute and may be caused by fever, fear, exercise, respiratory insufficiency, pleuritic pain, alkalosis, or pneumonia. Fatigue does not usually result in tachypnea. Normal respirations are even and regular. A normal respiratory rate is over 10 and under 24 respirations per minute. The bored client may exhibit a slower respiratory rate. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 21 Type: MCSA During the assessment of a client’s respiratory system, the nurse determines that the client’s expiration phase is the same length as the inspiration phase. The client’s respiratory rate is 14 per minute. The nurse would document this finding as: 1. obstructive breathing.

2. bradypnea. 3. respiratory distress. 4. normal. Correct Answer: 4 Rationale 1: A client exhibiting obstructive breathing will have a prolonged expiration. Rationale 2: Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute. Rationale 3: These findings do not indicate that the client is experiencing respiratory distress. Rationale 4: The finding describes eupnea, which is a normal breathing pattern. Global Rationale: The finding describes eupnea, which is a normal breathing pattern. Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute. A client exhibiting obstructive breathing will have a prolonged expiration. These findings do not indicate that the client is experiencing respiratory distress. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 22 Type: MCSA The nurse is preparing to assess an elderly client with emphysema. Which of the following anatomical changes would the nurse expect to find in this client? 1. Funnel chest 2. Barrel chest 3. Pigeon chest 4. Scoliosis Correct Answer: 2 Rationale 1: Funnel chest is a congenital deformity characterized by depression of the sternum and adjacent costal cartilage. Rationale 2: Clients with chronic obstructive pulmonary disease often have barrel chests. Aging can result in a barrel chest.

Rationale 3: Pigeon chest is a congenital deformity that is characterized by forward displacement of the sternum with depression of the adjacent costal cartilage. Rationale 4: Scoliosis is a condition in which there is lateral curvature and rotation of the thoracic and lumbar spine. Global Rationale: Clients with chronic obstructive pulmonary disease often have barrel chests. Aging can result in a barrel chest. Funnel chest is a congenital deformity characterized by depression of the sternum and adjacent costal cartilage. Pigeon chest is a congenital deformity that is characterized by forward displacement of the sternum with depression of the adjacent costal cartilage. Scoliosis is a condition in which there is lateral curvature and rotation of the thoracic and lumbar spine. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 23 Type: MCSA 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. Increased carbon dioxide levels. 4. Reduced oxygen capacity. Correct Answer: 3 Rationale 1: Pleurisy results in pleuritic pain. Rationale 2: This client is not at risk for developing congestive heart failure. Rationale 3: During expiration, the carbon dioxide is expelled. Poor exhalation leads to retention of carbon dioxide. Rationale 4: The client’s oxygen capacity at this time is increased. Global Rationale: During expiration, the carbon dioxide is expelled. Poor exhalation leads to retention of carbon dioxide. Pleurisy results in pleuritic pain. This client is not at risk for developing congestive heart failure. The client’s oxygen capacity at this time is increased. Cognitive Level: Remembering Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 24 Type: MCSA A client with chronic bronchitis has been admitted to the hospital. The nurse inspects the client while assessing the client’s respiratory system. Which of the following would be an expected finding? 1. Fever 2. Decreased respiratory rate 3. Use of accessory muscles 4. Dry cough Correct Answer: 3 Rationale 1: The client will not typically experience a fever. Fevers are associated with infections. Rationale 2: The respiratory rate may be elevated to compensate for the inability to breathe properly. Rationale 3: Chronic inflammation of the tracheobronchial tree leads to increased mucous production and blocked airways, causing decreased air movement in and out of the alveoli, which in turn causes the client’s respiratory rate to increase in order to compensate. The muscles of the chest wall work harder to try to pull more air into the alveoli, which causes increased chest wall expansion. The use of accessory muscles to breathe may be noted. Rationale 4: This client will most likely exhibit a chronic productive cough. Global Rationale: Chronic inflammation of the tracheobronchial tree leads to increased mucous production and blocked airways, causing decreased air movement in and out of the alveoli, which in turn causes the client’s respiratory rate to increase in order to compensate. The muscles of the chest wall work harder to try to pull more air into the alveoli, which causes increased chest wall expansion. The use of accessory muscles to breathe may be noted. The client will not typically experience a fever. Fevers are associated with infections. The respiratory rate may be elevated to compensate for the inability to breathe properly. This client will most likely exhibit a chronic productive cough. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment. Question 25 Type: MCSA

A 4-year-old child’s respiratory rate is 30 per minute. The mother states, “That seems like a really high number. My healthcare provider told me my respiratory rate is only 16 per minute.” Which of the following is the nurse’s best response? 1. “This is a normal finding for your child’s age.” 2. “Your child is exhibiting a sign of a respiratory infection.” 3. “Your child requires further assessment.” 4. “Your child may simply be anxious.” Correct Answer: 1 Rationale 1: It is normal for children up to the age of 5 to have respiratory rates of up to 35 per minute. Rationale 2: This child is not exhibiting a sign of a respiratory infection. Rationale 3: This respiratory rate is normal for this child’s age. The child does not require further assessment. Rationale 4: This respiratory rate is normal for this child’s age. The child’s respiratory rate will increase with anxiety and the child may exhibit tachypnea. Global Rationale: It is normal for children up to the age of 5 to have respiratory rates of up to 35 per minute. The other explanations are not appropriate for this situation. This child is not exhibiting a sign of a respiratory infection. This respiratory rate is normal for this child’s age. The child does not require further assessment. The child’s respiratory rate will increase with anxiety and the child may exhibit tachypnea. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 26 Type: MCSA The client is 36 weeks pregnant. The nurse is assessing the client’s respiratory system and finds that her respiratory rate is 24 breaths per minute. The client states that she sometimes experiences shortness of breath. Which of the following is the nurse’s best response? 1. “You have developed asthma during your pregnancy.” 2. “During your last trimester, it is normal for you to feel short of breath and to have a faster respiratory rate.” 3. “I’m going to have to notify your healthcare provider right now about these findings.”

4. “You have been infected with tuberculosis.” Correct Answer: 2 Rationale 1: The pregnant client has not developed asthma. Asthma is a chronic hyperreactive condition resulting in bronchospasm, mucosal edema, and increased mucus secretion. Usually occurs in response to inhaled irritants or allergens. Rationale 2: Shortness of breath, dyspnea, and an increased respiratory are normal findings during the last trimester of pregnancy as the woman’s chest expands to accommodate the growing baby. Rationale 3: These are normal findings for this pregnant client and the healthcare provider would not need to be notified. Rationale 4: The client has not developed tuberculosis. Global Rationale: Shortness of breath, dyspnea, and an increased respiratory are normal findings during the last trimester of pregnancy as the woman’s chest expands to accommodate the growing baby. The pregnant client has not developed asthma. Asthma is a chronic hyperreactive condition resulting in bronchospasm, mucosal edema, and increased mucus secretion. Usually occurs in response to inhaled irritants or allergens. These are normal findings for this pregnant client and the healthcare provider would not need to be notified. The client has not developed tuberculosis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 27 Type: MCSA The nurse is percussing the anterior chest of an elderly client. Which of the following would the nurse expect to find in this client? 1. Flatness 2. Dullness 3. Tympany 4. Hyperresonance Correct Answer: 4 Rationale 1: Percussion over bone will yield flat sounds.

Rationale 2: Percussion over solid organs or bones will yield a dull sound. Rationale 3: Tympany is heard when percussion is performed over an air bubble. Rationale 4: As a client ages, the function of the respiratory system becomes less efficient. The older adult’s lungs lose their elasticity, muscles begin to weaken, and bones lose their density. Trapping of air in the alveoli will produce a hyperresonance sound upon percussion of the chest. Global Rationale: As a client ages, the function of the respiratory system becomes less efficient. The older adult’s lungs lose their elasticity, muscles begin to weaken, and bones lose their density. Trapping of air in the alveoli will produce a hyperresonance sound upon percussion of the chest. Percussion over bone will yield flat sounds. Tympany is heard when percussion is performed over an air bubble. Percussion over solid organs or bones will yield a dull sound. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 28 Type: MCSA The nurse is caring for a teenager recently hospitalized with asthma. Several peers are preparing to visit the client and have brought gifts for the client. The nurse intervenes and prevents which of the following items from being brought into the patient’s room? 1. Magazines 2. Candy 3. MP3 player 4. Fresh flowers Correct Answer: 4 Rationale 1: Magazines would be an appropriate gift for this client. Rationale 2: Candy would be an appropriate gift for this client. Rationale 3: An MP3 player would be an appropriate gift for this client. Rationale 4: Limiting exposure to allergens, pollutants, and irritants in the client’s environment is important to control and limit problems associated with respiratory health. Assessment must identify exposure to irritants such as dust, tobacco, smoke, pollen, smog, asbestos, and vapors from household cleaners. The client’s friends should

be prevented from bringing anything in the room that may expose the client to anything that is known to be a trigger for the condition. Global Rationale: Limiting exposure to allergens, pollutants, and irritants in the client’s environment is important to control and limit problems associated with respiratory health. Assessment must identify exposure to irritants such as dust, tobacco, smoke, pollen, smog, asbestos, and vapors from household cleaners. The client’s friends should be prevented from bringing anything in the room that may expose the client to anything that is known to be a trigger for the condition. Objects void of any irritant would be the best selection for a gift. Magazines, candy, and an MP3 player would all be appropriate gifts for this client. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 29 Type: MCSA As the nurse assesses the pregnant client she states that she sometimes feels like she has difficulty breathing. The client has reached the 36th week of her pregnancy. The nurse realizes that the client’s difficulty is related to: 1. The fetus pushing the diaphragm upwards. 2. Fatigue due to the pregnancy. 3. Anxiety about her impending delivery. 4. Contractions. Correct Answer: 1 Rationale 1: While the pregnant female is at rest, the diaphragm rises into the chest to accommodate the fetus. Shortness of breath and dyspnea, especially in the last trimester, are common as the maternal and fetal demand for oxygen increases. Rationale 2: This feeling is not likely due to fatigue. Rationale 3: This feeling is not likely due to anxiety. Rationale 4: This feeling is not likely due to contractions. Global Rationale: While the pregnant female is at rest, the diaphragm rises into the chest to accommodate the fetus. Shortness of breath and dyspnea, especially in the last trimester, are common as the maternal and fetal demand for oxygen increases. The remaining choices are not applicable for this situation. Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 30 Type: MCMA The nurse is examining an African American client. When compared to Caucasians, which of the following conditions is this client at a higher risk for developing? Standard Text: Select all that apply. 1. Asthma 2. Sarcoidosis 3. Tuberculosis 4. Obstructive sleep apnea 5. Chronic bronchitis Correct Answer: 1,2,3,4 Rationale 1: Asthma. Asthma occurs more frequently in African Americans than in Caucasians. Rationale 2: Sarcoidosis. Sarcoidosis occurs more frequently and with greater severity in African Americans than in Caucasians. Rationale 3: Tuberculosis. Contracting tuberculosis is eight times more likely in African Americans than in Caucasians. Rationale 4: Obstructive sleep apnea. Obstructive sleep apnea (OSA) is twice as likely to be experienced by young African Americans compared to young Caucasians. Rationale 5: Chronic Bronchitis. African Americans are not necessarily more likely to develop chronic bronchitis. Global Rationale: Asthma, sarcoidosis, TB, and obstructive sleep apnea occur more frequently in African Americans than in Caucasians. African Americans are not necessarily more likely to develop chronic bronchitis. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 31 Type: MCMA 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? Standard Text: Select all that apply. 1. “Infants should always be placed to sleep on their backs.” 2. “Children should be taught to wash their hands.” 3. “Caregivers should ensure that the children’s toys are age-appropriate.” 4. “Parents should be educated about the importance of immunizations.” 5. “Caregivers should inspect the children’s toys for small possibly inhalable parts.” Correct Answer: 1,2,3,4,5 Rationale 1: “Infants should always be placed to sleep on their backs.” Infants who sleep on their backs have a reduced risk of developing sudden infant death syndrome (SIDS). Rationale 2: “Children should be taught to wash their hands.” Children should be taught hygiene measures such as handwashing to prevent the spread of infection. Rationale 3: “Caregivers should ensure that the children’s toys are age-appropriate.” Age-appropriate toys should be provided for children to ensure that young infants or children do not inhale small parts or choke on plastic bags that may found in toys meant to be played with by older children. Rationale 4: “Parents should be educated about the importance of immunizations.” Children should be immunized to prevent the spread of preventable infections. Rationale 5: “Caregivers should inspect the children’s toys for small possibly inhalable parts.” Some toys may include inhalable parts. Caregivers should ensure that they are providing toys that are safe. Global Rationale: Infants who sleep on their backs have a reduced risk of developing sudden infant death syndrome (SIDS). Children should be taught hygiene measures such as handwashing to prevent the spread of infection. Age-appropriate toys should be provided for children to ensure that young infants or children do not inhale small parts or choke on plastic bags that may found in toys meant to be played with by older children. Children should be immunized to prevent the spread of preventable infections. Some toys may include inhalable parts. Caregivers should ensure that they are providing toys that are safe. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.8: Discuss the objectives related to the overall health of the respiratory system as presented in Healthy People 2020. Question 32 Type: MCSA The nurse is assessing a 1-month-old infant’s respiratory system and sees that the infant is primarily using abdominal muscles to breathe and has an irregular breathing pattern. The nurse recognizes that this finding is: 1. A sign of severe respiratory distress. 2. An indicator that the infant has developed pneumonia. 3. A normal finding. 4. An indicator that the infant has developed a pneumothorax. Correct Answer: 3 Rationale 1: Intercostal muscle retraction and prominent sternocleidomastoids may be seen in respiratory distress. This infant is not exhibiting any signs of respiratory distress. Rationale 2: Infants are more susceptible to pneumonia than other populations, but this infant is not exhibiting any clinical manifestations of pneumonia. Rationale 3: Abdominal breathing is the normal pattern for an infant and continues during childhood until ages 5–7, when the child develops costal breathing patterns. It is normal for an infant to exhibit an irregular breathing pattern. Rationale 4: A pneumothorax is a condition in which air moves into the pleural space and causes partial or complete collapse of the lung. The client with a pneumothorax will exhibit tachypnea, decreased expansion of the chest wall on the affected side, and a tracheal shift to the unaffected side. Global Rationale: Abdominal breathing is the normal pattern for an infant and continues during childhood until ages 5–7, when the child develops costal breathing patterns. It is normal for an infant to exhibit an irregular breathing pattern. Intercostal muscle retraction and prominent sternocleidomastoids may be seen in respiratory distress. This infant is not exhibiting any signs of respiratory distress. Infants are more susceptible to pneumonia than other populations, but this infant is not exhibiting any clinical manifestations of pneumonia. A pneumothorax is a condition in which air moves into the pleural space and causes partial or complete collapse of the lung. The client with a pneumothorax will exhibit tachypnea, decreased expansion of the chest wall on the affected side, and a tracheal shift to the unaffected side. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.9: Apply critical thinking in selected simulations related to physical assessment of the respiratory system.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 16 Question 1 Type: MCMA 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? Standard Text: Select all that apply. 1. Caucasian race 2. Positive family history 3. Low socioeconomic status 4. Hormone replacement therapy 5. Female age 35 to 40 Correct Answer: 1,2,3,4 Rationale 1: Caucasian race. Caucasian females, especially over the age of 40 have a higher risk of developing breast cancer than any other race or ethnic group. Rationale 2: Positive family history. A positive family history of breast cancer places an individual at a higher risk of developing breast cancer. The individual is at an even greater risk if the family member developed breast cancer prior to menopause. Rationale 3: Low socioeconomic status. Lower socioeconomic status places an individual at risk for breast cancer for a number of reasons, including lack of education on preventative measures and diagnostic recommendations; fear that breast cancer is not treatable and has a high mortality rate, thus they avoid diagnosis; and the mother of the family in lower socioeconomic groups often places her family’s health care needs above hers. Rationale 4: Hormone replacement therapy. Hormone replacement therapy is linked to higher incidence of breast cancer. Rationale 5: Female age 35 to 40. Females between the ages of 35 to 40 have not been found to have a high incidence of breast cancer. Global Rationale: Caucasian females over the age of 40, positive family history, low socioeconomic status, and taking hormone replacement therapy are risk factors for breast cancer. Females from 35 to 40 years of age are not at a high risk for developing breast cancer. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of female breasts. Question 2 Type: MCSA 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. congenital anomaly. 2. highly irregular finding. 3. reason to call in a specialist. 4. common finding in newborns. Correct Answer: 4 Rationale 1: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones. This is not considered a congenital anomaly. Rationale 2: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones; therefore, this is not considered an irregular finding. Rationale 3: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones; therefore, there would be no reason to contact a specialist. Rationale 4: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones; therefore, this assessment finding is common in newborns. Global Rationale: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy. Some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones. This is neither irregular nor hereditary, and there is no reason to call on a specialist. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae.

Question 3 Type: MCSA 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. Prosthestic devices 2. Support bras 3. Plastic surgery 4. Physical therapy Correct Answer: 2 Rationale 1: A prosthetic device is not indicated as treatment in this scenario, so discharge teaching for such devices is not necessary. Rationale 2: Discharge teaching regarding the need for the client to wear a support bra would be indicated in this scenario since injury has occurred to the left pectoralis major and serratus anterior muscles, as these comprise the suspensory ligaments of the breasts. Rationale 3: Plastic surgery is not indicated as treatment in this scenario, so discharge teaching for such devices is not necessary. Rationale 4: Physical therapy is not indicated as treatment in this scenario, so discharge teaching for such devices is not necessary. Global Rationale: The overall contour of the breasts is determined by the suspensory ligaments, which provide support, and the major muscles of support are the pectoralis major and serratus anterior muscles. The major function of the muscles of the chest wall is to support breast and lymphatic tissue. Undergarments, which provide needed support after discharge, are an important part of the client’s recovery—for emotional as well as physical health. Although prostheses, plastic surgery, and physical therapy may all be part of the comprehensive care plan, supporting the breast and lymph tissue until such time as muscle strength is restored or reconstructed would be an important nursing intervention. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae. Question 4 Type: MCSA

The nurse is using inspection to assess the breasts of a female client. Which of the following findings might the nurse obtain using this assessment technique? 1. Symmetry 2. Hard nodules 3. Tenderness 4. Skin consistency Correct Answer: 1 Rationale 1: Symmetry of the breasts indicates that both breasts are nearly the same size and shape. This assessment is performed by the technique of inspection. Rationale 2: Hard nodules in the breast tissue cannot be assessed by inspection. Palpation would be necessary for this type of assessment. Rationale 3: Tenderness cannot be assessed by inspection. Palpation would be necessary for this type of assessment. Rationale 4: Skin thickening cannot be assessed by inspection. Palpation would be necessary for this type of assessment. Global Rationale: Symmetry is the only finding that the nurse would assess using the technique of inspection when examining the breasts. The remaining findings would all be obtained using the technique of palpation. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4: Describe techniques for assessment of the breasts and axillae. Question 5 Type: MCMA The nurse is teaching an older adult client about breast self-examination (BSE). Which of the following should the nurse provide during this instruction? Standard Text: Select all that apply. 1. Additional lighting 2. Increased time 3. Opportunity for questions

4. Large-print handouts 5. A quiz at the end of the instruction Correct Answer: 1,2,3,4 Rationale 1: Additional lighting. Additional lighting may be necessary when teaching the older adult client about BSE due to failing eyesight in some of these clients. Rationale 2: Increased time. More time may be required for the focused interview of the older client who may have a more difficult time talking about something as private as the breasts. Rationale 3: Opportunity for questions. Allowing an ample amount of opportunity for questions is necessary for some older adults who may take longer to process new information. Rationale 4: Large-print handouts. Large-print handouts may be necessary when teaching the older adult client about BSE due to failing eyesight in some of these clients. Rationale 5: A quiz at the end of the instruction. A quiz at the end of the instruction is not indicated as this may cause the client to feel undue stress. Global Rationale: More time may be required for the focused interview of the older client who may have a more difficult time talking about something as private as the breasts. Limited range of motion and failing eyesight are some of the physical changes that accompany the aging process. Providing additional lighting, moving at a slower pace, and using handouts or pamphlets with large print may be helpful. A quiz would not be indicated as this may cause the client to experience undue stress. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.7: Identify anatomical, physiologic, developmental, psychosocial, and cultural variation that guide assessment. Question 6 Type: MCSA The nurse is asking a client questions regarding lifestyle patterns. Which of the following statements by the client would alert the nurse to possible risk for breast cancer? 1. “I work in a chemical factory.” 2. “I drink two glasses of wine each night.” 3. “I have smoked two packs of cigarettes daily for four years.” 4. “I occasionally have unprotected sexual contact with unknown partners.”

Correct Answer: 2 Rationale 1: Exposure to chemicals by working in a chemical factory would place the client at risk for developing lung-related cancers or other body system cancers or disease. Rationale 2: Research indicates that alcohol intake in excess of nine drinks per week may increase a woman’s risk of developing breast cancer. Two glasses of wine each night totals 14 drinks per week. Rationale 3: Smoking two packs of cigarettes daily for four years would place the client at risk for developing lung-related cancers or disease. Rationale 4: Occasional unprotected sexual contact with unknown partners increases risk for STDs, HIV, as well as cervical cancer. Global Rationale: Research indicates that a high-fat diet may increase a woman’s risk of developing breast cancer as well as alcohol intake in excess of nine drinks per week. Exposure to chemicals and cigarette smoke would place the client at risk for developing lung-related cancers or disease, and unprotected sexual contact increases risk for STDs, HIV, as well as cervical cancer. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.2: Develop questions to be used when completing the focused interview. Question 7 Type: MCSA The nurse is teaching self–breast examination to a client and demonstrates inspecting the breasts with arms over the head. The client asks the nurse why this is necessary. The nurse would respond with which of the following? 1. “It allows any masses to bulge forward to be seen.” 2. “This is the only position to detect Paget’s disease.” 3. “This is the best position to look for skin dimpling.” 4. “It is the only way to look for nipple retraction.” Correct Answer: 3 Rationale 1: Masses are rarely visible with inspection so stating that this position would allow for any masses to bulge forward to be seen is an inaccurate statement. Rationale 2: Paget’s disease is a rare type of breast cancer typified by a red, scaly, eczema-like area over the nipple and, like nipple retraction, does not have to be visualized with the arms over the head.

Rationale 3: This statement is accurate since recent dimpling of the skin over a mass is often a visible sign of breast cancer, and it is accentuated with the client’s arms over the head. Rationale 4: Nipple retraction is a possible sign of breast cancer, but it does not require the arms over the head for visualization. Global Rationale: Dimpling of the skin over a mass is usually a visible sign of breast cancer. Dimpling is accentuated with the client’s arms over the head. Paget’s disease is a rare type of breast cancer typified by a red, scaly, eczema-like area over the nipple and, like nipple retraction, does not have to be visualized with the arms over the head. Masses are rarely visible with inspection. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.4: Describe techniques for assessment of the breasts and axillae Question 8 Type: MCSA The nurse is assessing a client and confirms the presence of galactorrhea. The nurse understands that this finding is: 1. suggestive of endocrine disorders. 2. may indicate a malignancy. 3. probably an infection. 4. usually indicative of lactation. Correct Answer: 1 Rationale 1: Galactorrhea is lactation not associated with childbearing and occurs most commonly with endocrine disorders or medications, including some antidepressant and antihypertensive medications. Rationale 2: Unilateral discharge from the nipple is suggestive of benign breast disease, an intraductal papilloma, or it may indicate a malignancy. Rationale 3: Infections of the breast often cause enlargement and tenderness of the axillary lymph nodes. Rationale 4: Normal lactation is associated with childbearing and is not called galactorrhea. Global Rationale: Galactorrhea is lactation not associated with childbearing and occurs most commonly with endocrine disorders or medications, including some antidepressants and antihypertensives. Unilateral discharge from the nipple is suggestive of benign breast disease, an intraductal papilloma, or cancer. Infections of the breast cause enlargement and tenderness of the axillary lymph nodes.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae Question 9 Type: MCMA 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? Standard Text: Select all that apply. 1. Straw-colored discharge from the nipples 2. Freely movable masses 3. Hard, fixed nodules 4. Thickened breast tissue 5. Masses with well defined boundaries Correct Answer: 1,2,4,5 Rationale 1: Straw-colored discharge from the nipples. Straw-colored discharge from the nipples is common with benign breast disease. Discharge from the nipples may be clear, straw-colored, milky, or green. Rationale 2: Freely movable masses. Masses with benign breast disease are generally freely movable. Rationale 3: Hard, fixed nodules. Hard, fixed nodules are more commonly associated with cancer of the breast. Rationale 4: Thickened breast tissue. The symptoms of benign breast disease are a result of fibrosis, which is a thickening of the normal breast tissue and may be accompanied by cyst formation. Rationale 5: Masses with well defined boundaries. The masses of benign breast disease are typically well demarcated (having defined boundaries). Global Rationale: Upon palpation of fibrocystic breasts, the masses feel soft, well demarcated and freely movable. Discharge from the nipples may be clear, straw-colored, milky, or green. These symptoms are a result of fibrosis, which is a thickening of the normal breast tissue and may be accompanied by cyst formation. Hard, fixed nodules are suggestive of cancer of lymphoma. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae. Question 10 Type: MCSA The nurse is teaching a client with benign breast disease about symptom relief. Which of the following topics would the nurse include in this session? 1. Avoiding all fat in the diet 2. Wearing a firm bra 3. Limiting salt intake 4. Drinking tea instead of coffee Correct Answer: 3 Rationale 1: Avoiding all fat in the diet is not advisable for any client; limiting the amount of saturated fats may help alleviate pain associated with benign breast disease. Rationale 2: Wearing a firm bra has not been identified as treatment method for pain associated with benign breast disease. Rationale 3: Limiting salt intake has been found to help alleviate pain associated with benign breast disease. Rationale 4: Limiting caffeine is advisable to help alleviate the pain associated with benign breast disease; however, drinking tea instead of coffee would not help since both contain caffeine. Global Rationale: Symptom management includes such things as pharmacological hormones, diuretics, limiting caffeine, wearing a supportive bra, and decreasing salt intake may help relieve symptoms of breast pain and tenderness, especially in the premenstrual period. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of female breasts. Question 11 Type: MCSA 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 know that I need to do monthly self–breast exams.” 3. “I’ll be able to know about problems if I see changes in my chest.” 4. “Breast cancer is not something I have to worry about.” Correct Answer: 2 Rationale 1: “I need to be concerned only if I have pain in my chest” is an inaccurate statement since pain may or may not be present with male breast cancer. Rationale 2: “I know that I need to do monthly self–breast exams” is a correct statement as breast cancer in the male is usually identified as a hard nodule fixed to the nipple and underlying tissue and is best detected by palpation. Rationale 3: “I’ll be able to know about problems if I see changes in my chest” is inaccurate since the most common area for nodules to occur in the male breast is near the nipple, other signs like dimpling, asymmetry, peau d’orange, and areolar color changes may not be as noticeable. Rationale 4: “Breast cancer is not something I have to worry about” is an inaccurate statement since teaching the male client to do monthly breast self-examinations is as important as for the female client for early detection of breast cancer. Global Rationale: Teaching the male client to do monthly breast self-examinations is as important as it is for the female client. Breast cancer in the male is usually identified as a hard nodule fixed to the nipple and underlying tissue and is best detected by palpation. Normally, the male breast feels like a thin disc of tissue under a flat nipple and areola. Pain may or may not be present. Since the most common area for nodules to occur in the male breast is near the nipple, other signs like dimpling, asymmetry, peau d’orange, and areolar color changes may not be as noticeable. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.4: Describe techniques for assessment of the breasts and axillae. Question 12 Type: MCSA A pregnant client expresses concern about performing breast self-examination during pregnancy since her breasts are tender. Which of the following would be the best response by the nurse in this situation? 1. “All you need to do is just concentrate on having a healthy baby for now.” 2. “You can wait until your breasts are no longer tender, and then resume your self-exams.”

3. “It’s very important for you to be familiar with the changes in your breasts.” 4. “Breast cancer during pregnancy is rare, so don’t worry about it.” Correct Answer: 3 Rationale 1: “All you need to do is just concentrate on having a healthy baby for now” is inappropriate since it leads the client to believe that it is not possible to have breast cancer during pregnancy. Self–breast examination should be implemented throughout the pregnancy and during lactation. Rationale 2: “You can wait until your breasts are no longer tender, and then resume your self-exams” is an incorrect statement since breast tenderness may continue throughout the pregnancy and lactation period. Self– breast examination should be implemented throughout the pregnancy and during lactation. Rationale 3: “It’s very important for you to be familiar with the changes in your breasts” is the best response by the nurse since, although rare, breast cancer can occur during pregnancy and lactation; therefore, self–breast examination should be implemented throughout the pregnancy and during lactation. Rationale 4: While breast cancer during pregnancy is rare, the statement: “Breast cancer during pregnancy is rare, so don’t worry about it” is inappropriate since breast cancer can occur during pregnancy and lactation. Self–breast examination should be implemented throughout the pregnancy and during lactation. Global Rationale: During pregnancy, breast self-examination needs to be done and the procedure is the same, even though the breast tissue will be firmer, larger, and possibly more tender. Breast cancer needs to be identified as soon as possible and is treated on an individual basis. It may not be common for breast cancer to occur during pregnancy, but monitoring for it does need to continue. Therefore, self–breast examination must be implemented throughout the pregnancy and during lactation. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae Question 13 Type: MCSA The nurse is interviewing a 37-year-old client for breast cancer risks. The nurse understands that the client knows the risks associated with breast cancer when which of the following comments is made? 1. “I know my risk for breast cancer increases with age.” 2. “A mammogram every three years is my goal.” 3. “I will see my healthcare provider every two years for a breast examination.” 4. “My family history is negative so I do not need to worry.”

Correct Answer: 1 Rationale 1: “I know my risk for breast cancer increases with age” is the correct statement since breast cancer risks increase significantly after the age of 35 to 40. Rationale 2: “A mammogram every three years is my goal” is not an accurate response. Mammography screening is dependent on several factors. Biennial screening is suggested between the ages of 50 and 74 years. Beginning biennial mammography before the age of 50 is based on cancer risk, and values regarding the benefit and harm associated with mammography. Rationale 3: “I will see my healthcare provider every two years for a breast examination” is not an accurate response. Annual breast examination by a healthcare provider every 3 years for women from age 20 to 40 years, and annually thereafter, is suggested. Rationale 4: “My family history is negative so I do not need to worry” is not an accurate response. The client should be aware of current screening guidelines regardless of family history. Global Rationale: The risk of breast cancer increases with aging, especially after 35–40 years of age. The most current American Cancer Society guidelines for breast cancer screening include: Mammography biennial screening between the ages of 50 and 74 years; beginning biennial mammography before the age of 50 should be an individual decision based on cancer risk, and values regarding benefit and harm associated with mammography; annual breast examination by a healthcare provider every 3 years for women from age 20 to 40 years, and annually thereafter; self–breast examination is an option for women to consider beginning at the age of 20 All clients, regardless of family history, should be aware of screening guidelines. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of female breasts Question 14 Type: MCMA The nurse is compiling statistics for a breast cancer awareness presentation for a group of women. The nurse would correctly use which of the following facts about breast cancer? Standard Text: Select all that apply. 1. Breast cancer is one of the most common cancers in females. 2. Rates are on the decline. 3. Associated mortality has declined. 4. Diagnostics have improved. 5. 25% of females in Western countries are genetically predisposed.

Correct Answer: 1,3,4 Rationale 1: Breast cancer is one of the most common cancers in females. Breast cancer, along with skin cancer, is the most common cancers in females. Rationale 2: Rates are on the decline. Breast cancer rates are increasing. Rationale 3: Associated mortality has declined. Rates of death from breast cancer have declined to approximately 1 in 35 women diagnosed with the disease. Rationale 4: Diagnostics have improved. Diagnostics, such as mammography and breast ultrasound, have significantly improved. Rationale 5: 25% of females in Western countries are genetically predisposed. 10%, rather than 25%, of females in Western countries are genetically predisposed to breast cancer. Global Rationale: All of the statements are true with the exception of breast cancer rates, which are actually on the increase, not the decline, and 10 % of females in Western countries, rather than 25%, are genetically predisposed to breast cancer. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.2: Develop questions to be used when completing the focused interview. Question 15 Type: MCSA The nurse is performing a breast examination and is palpating into the tail of Spence. The nurse understands that this is necessary for which of the following reasons? 1. It does not contain any lymph nodes. 2. It can show the difference between fibrocystic disease and fibroadenomas. 3. Breast cancer occurs more frequently in this area. 4. Peau d’orange may occur in this area of the breast. Correct Answer: 3 Rationale 1: The area of the tail of Spence is in the upper outer quadrant of the breast into the axillary region, which does contain lymph nodes; therefore, this statement is not accurate. Rationale 2: It would be difficult to detect the difference between fibrocystic disease, breast cancer, and fibroadenomas by palpation alone—correlating physical symptoms with physical findings during exam and possibly a biopsy would make the definitive diagnoses.

Rationale 3: Breast cancer does occur more frequently in this area. The incidence of breast cancers is highest in the upper outer quadrant, including the axillary tail of Spence. Rationale 4: Peau d’orange and Paget’s disease are changes in the breast skin and nipple area associated with forms of cancer; therefore, palpation in the tail of Spence area would not be a detection method for these abnormalities. Global Rationale: The incidence of breast cancers is highest in the upper outer quadrant, including the axillary tail of Spence. Masses in the tail must be distinguished from enlarged lymph nodes. It would be difficult to detect the difference between fibrocystic disease, breast cancer, and fibroadenomas by palpation alone—correlating physical symptoms with physical findings during exam and possibly a biopsy would make the definitive diagnoses. Peau d’orange and Paget’s disease are changes in the breast skin and nipple area associated with forms of cancer. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4: Describe techniques for assessment of the breasts and axillae Question 16 Type: MCSA 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. Fibrocystic disease 3. Breast malignancy 4. Intraductal papillomas Correct Answer: 4 Rationale 1: Discharge associated with mammary duct ectasia is thick and sticky, rather than thin and watery, as a result of inflammation of the lactiferous ducts. Rationale 2: Fibrocystic disease is first seen when women are in their twenties, and discharge is typically strawcolored, clear, milky, or green. Rationale 3: Malignancy that affects the nipple must be correlated with other physical findings, mammogram, and biopsy. In addition, discharge is not typically thin and watery with breast malignancy. Rationale 4: Intraductal papillomas, which are small growths of epithelial cells that extend into the lumen of the lactiferous ducts, are the primary cause of thin, watery nipple discharge in women who are not pregnant or lactating and are more commonly found in menopausal women.

Global Rationale: Intraductal papillomas are the primary cause of nipple discharge in women who are not pregnant or lactating and are more commonly found in menopausal women. Fibrocystic disease is first seen when women are in their twenties, and discharge may be straw-colored, clear, milky, or green. Discharge associated with mammary duct ectasia is thick and sticky. Malignancy that affects the nipple must be correlated with other physical findings, mammogram, and biopsy. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae. Question 17 Type: MCSA The nurse is educating a prenatal class about lactation when one of the clients asks how milk is produced. The nurse would correctly identify which of the following structures as responsible for milk production? 1. Montgomery’s glands 2. Areola 3. Acini cells 4. Mammary ridge Correct Answer: 3 Rationale 1: Montgomery’s glands are sebaceous glands; therefore, no milk production occurs from these glands. Rationale 2: The areola circular wrinkled pigmented skin surrounding the nipple and is not responsible for milk production. Rationale 3: Each lobe in the breast contains approximately 20 to 40 lobules that contain the acini cells, which produce milk. Rationale 4: The mammary ridge is comprised of supernumerary nipples or breast tissue and extends from each axilla to the groin. No milk production occurs from this area. Global Rationale: The acini cells are contained within the lobules that produce milk. The remaining structures are not responsible for milk production. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae.

Question 18 Type: MCSA During the breast examination on a client, the nurse palpates a small, subclavicular node on the right side of the client’s chest. The priority action at this time is for the nurse is to do which of the following? 1. Call the primary care provider. 2. Ask the client if they have a family history of breast cancer. 3. Continue with the exam. 4. Schedule a mammogram for the next available appointment. Correct Answer: 3 Rationale 1: Calling the primary care provider should not occur until the exam is complete. This will allow for all information, such as the size and location of any and all palpable masses, as well as subjective information from the client to be reported to the primary care provider. Rationale 2: Asking the client at this point in the examination if she has a family history of breast cancer would most likely alarm the client that there is something wrong. This question should be asked during the client interview. Rationale 3: Usually nodes are nonpalpable, but subclavicular nodes must be assessed as part of the examination. It would be important for the nurse to complete the exam, in order to document size, location of any and all palpable masses. Documentation of the client’s report to corroborate findings is also important. Reporting these findings in completeness to the primary care provider would be the next step, and any further follow-up would be determined by that provider, along with the client’s input. Rationale 4: Scheduling a mammogram for the next available appointment would be inappropriate at this point. The examination should be completed and all information reported to the primary care provider, who will determine, with the input of the client, the necessity of scheduling a mammogram. Global Rationale: Usually nodes are nonpalpable, but subclavicular nodes must be assessed as part of the examination. It would be important for the nurse to complete the exam, in order to document size, location of any and all palpable masses. Documentation of the client’s report to corroborate findings is also important. Reporting these findings in completeness to the primary care provider would be the next step, and any further follow-up would be determined by that provider, along with the client’s input. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae.

Question 19 Type: HOTSPOT The nurse is preparing a poster on self–breast examination and is labeling the anatomical structures of the breast. Identify the area that the nurse should label as the tail of Spence.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The tail of Spence, also called the axillary tail, is the portion of breast tissue that expends superiolaterally into the axilla. Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae. Question 20 Type: MCMA The nurse is planning to perform a breast examination of a female client. In preparing the client, the nurse will inform the client to expect which of the following techniques?

Standard Text: Select all that apply. 1. Inspection 2. Palpation 3. Percussion 4. Auscultation 5. Client interview Correct Answer: 1,2,5 Rationale 1: Inspection, Inspection involves looking at skin color, structures of the breast, and the appearance of the axillae Rationale 2: Palpation, Palpation involves feeling the breast tissue, nipples, and axillary regions for any abnormalities. Rationale 3: Percussion, Percussion is a physical assessment technique that is not necessary for breast tissue. Rationale 4: Auscultation, Auscultation is a physical assessment technique that is not necessary for breast tissue. Rationale 5: Client interview, The client interview is necessary in order to obtain subjective information regarding the client’s state of breast health or illness. Global Rationale: Inspection, palpation, and the client interview are necessary for a complete assessment of the breasts. Percussion and auscultation are not assessment techniques used on breast tissue. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.3: Explain client preparation for examination of the breasts and axillae. Question 21 Type: MCSA While the nurse is counseling a client about fibrocystic breast disease, the client asks if having this disorder will lead to cancer. The nurse’s best response is: 1. “There is no direct link between this disease and breast cancer.” 2. “You will need to ask the primary healthcare provider that question.” 3. “This disease is a form of cancer.” 4. “Why are you so worried about this?”

Correct Answer: 1 Rationale 1: This is the most appropriate response since research indicates that no direct link has been found between fibrocystic disease and breast cancer. However, the primary health care provider will want to monitor the client with fibrocystic breast disease because some clients with the disease develop ductal hyperplasia and dysplasia, which may eventually develop into noninvasive intraductal, lobular, or intraepithelial carcinoma. Rationale 2: “You will need to ask the primary care provider that question” is inappropriate because this statement does not address the client’s question. Rationale 3: Fibrocystic breast disease is a thickening of the normal breast tissue, which may be accompanied by cyst formation. The statement “This disease is a form of cancer” is incorrect. Rationale 4: “Why are you so worried about this?” is not an appropriate statement as it disregards the client’s feelings. Global Rationale: There is no direct link between fibrocystic disease and the incidence of cancer. The disease is not a form of cancer, and the remaining two choices do not address the client’s concerns. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.7: Identify anatomical, physiologic, developmental, psychosocial, and cultural variation that guide assessment. Question 22 Type: MCSA The nurse working in a predominately Hispanic community outlines a breast health screening. The nurse is aware that: 1. Breast cancer is the leading cause of cancer death in Hispanic women. 2. This cultural group is strict about performing monthly self breast exams. 3. Hispanic women have a higher incidence of breast cancer after age 40. 4. Hispanic women have an open attitude about private issues. Correct Answer: 1 Rationale 1: While Hispanic women, along with Asian women, have the lowest rates of breast cancer, breast cancer is the leading cause of cancer death in Hispanic women. Rationale 2: It is common for this particular cultural group to believe that looking at or touching themselves is prohibited; therefore, this culture is not strict about performing monthly self–breast exams.

Rationale 3: Caucasian women over the age of 40 have a higher incidence of breast cancer than women in all other racial and ethnic groups. Rationale 4: Many Hispanic women do not have an open attitude about private issues. Females in many cultures have concerns about discussing breast health or disease, as well as disrobing and being examined by others, especially when the examiner is of the opposite sex. Global Rationale: Breast cancer is the leading cause of cancer death in Hispanic women, and it is common for this particular cultural group to believe that looking at or touching themselves is prohibited. Caucasian women have a higher incidence of breast cancer after age 40 than do women in other racial and ethnic groups. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of female breasts. Question 23 Type: HOTSPOT The nurse is aware that the client with breast cancer is most at risk for metastasis of the disease through the lymphatic system. Identify which lymph nodes are most responsible for the spread of breast cancer via the lymphatic system:

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The internal mammary nodes drain toward the abdomen and the opposite breast. Most of the lymph from the rest of the breast drains toward the axilla and subclavicular region. Therefore, cancer within the breast can spread through the lymphatic system via the subclavicular nodes, into deep channels within the chest or abdomen, and even to the opposite breast. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae. Question 24 Type: MCSA The mother of a 9-year-old girl voices concern to the nurse regarding her daughter’s breast development and breast tenderness. The nurse’s best response to the mother is: 1. “I understand your concern. 9 years old is very young for your daughter’s breasts to be developing. Children this age are not equipped to deal with these changes.” 2. “I will let her primary care provider know that an exam is necessary due to your daughter’s symptoms.” 3. “I wouldn’t worry about it unless the tenderness continues or worsens.” 4. “Breast enlargement and tenderness is common between the ages of 9 to 13, but I will inform her primary care provider of your concerns.” Correct Answer: 4 Rationale 1: “I understand your concern. 9 years old is very young for your daughter’s breasts to be developing. Children this age are not equipped to deal with these changes,” is incorrect since 9 years old is not too young for female breast development, and if proper information is given to the girl she will be able to deal with these changes.

Rationale 2: “I will let her primary care provider know that an exam is necessary due to your daughter’s symptoms,” does not directly address the mother’s concerns; rather, it will instill more fear as this statement will lead the mother to believe there may be a problem. Rationale 3: “I wouldn’t worry about it unless the tenderness continues or worsens,” disregards the mother’s concerns, and although these symptoms are common for this age, the primary care provider should be aware of the situation. Rationale 4: “Breast enlargement and tenderness is common between the ages of 9 to 13, but I will inform her primary care provider of your concerns,” is the best response because it directly answers the concerns of the mother with facts, and the primary care provider will be made aware of the situation. Global Rationale: Breast enlargement and tenderness commonly begins with the onset of puberty, which is usually between the ages of 9 to 13. Letting the primary care provider know the mother’s concerns addresses the worry the mother is experiencing. Responses 2 and 3 do not properly address the mother’s concerns. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.7: Identify anatomic, physiologic, developmental, psychosocial, and cultural variation that guide assessment. Question 25 Type: MCSA The nurse is performing a breast assessment of an Asian adult female. Which of the following should the nurse do first? 1. Ask the client if she has ever had any breast disease such as cancer of the breast, fibrocystic disease, or fibroadenoma. 2. Ask the client to disrobe from the waist up and place a gown on with the opening to the front. 3. Ask the client if she has noticed any changes in her breasts such as lumps, thickening, or discharge from the nipples. 4. Ask the client how she feels about her breasts. Correct Answer: 3 Rationale 1: Initially asking the Asian client about breast disease may be too aggressive in the interview process and make the client feel uncomfortable about such issues. Rationale 2: Asking the client to disrobe as one of the initial steps in the interview process does not allow for rapport to be established, especially with a client from this culture. Rationale 3: Asking the client if she has noticed any changes in her breasts would be a more effective way to lead into the entire breast assessment process and lead to developing rapport with the client.

Rationale 4: Asking an Asian client how she feels about her breasts in the first stage of the assessment process would likely block communication and make the client feel uncomfortable about the assessment. Global Rationale: Asking the client if she has noticed any changes in her breasts may open up rapport with this client. Females of Asian descent are often stoic and do not seek preventive care so this would be a good way to lead into the entire focus assessment and physical exam. Immediately asking her questions about breast disease, how she feels about her breasts, or having her disrobe would likely be uncomfortable for a client from this culture. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.3: Explain client preparation for examination of the breasts and axillae. Question 26 Type: MCSA The nurse is teaching a childbirth education class. The nurse would be correct in stating that which of the following commonly leaks from the nipples during the last month of pregnancy? 1. Blood 2. Milk 3. Serum 4. Colostrum Correct Answer: 4 Rationale 1: It is not normal for blood to be discharged from the nipples. This is often a sign of cancer of the breast. Rationale 2: Milk is not discharged from the breast until lactation following delivery occurs. Rationale 3: Serous discharge may be a symptom of benign breast disease or cancer of the breast. Discharge from the nipples may be clear, straw colored, milky, or green with benign breast disease, and discharge may be clear or bloody with cancer of the breast. Rationale 4: Colostrum is a form of milk produced by the mammary glands toward the end of pregnancy, and it is normal for some to leak from the nipples. It appears as a thick yellow discharge. Global Rationale: Colostrum is a form of milk produced by the mammary glands toward the end of pregnancy, and it is normal for some to leak from the nipples. Its appearance is a thick yellow discharge. The other options are not a normal occurrence at the end of a pregnancy. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16.7: Identify anatomical, physiologic, developmental, psychosocial, and cultural variation that guide assessment. Question 27 Type: MCMA During a health assessment, a male client voices concern that he is at risk for breast cancer. The nurse is aware that further evaluation of the client’s history should focus on predisposing factors that increase the chance for breast cancer in males. The interview should include questions related to which of the following factors? Standard Text: Select all that apply. 1. Previous history of taking testosterone 2. The client’s mother having a history of breast cancer 3. History of cirrhosis of the liver 4. History of kidney disease 5. History of radiation treatment for lung cancer Correct Answer: 2,3,5 Rationale 1: Previous history of taking testosterone. Previously taking testosterone does not increase the risk of male breast cancer. Estrogen therapy in males does increase the risk for male breast cancer. Rationale 2: The client’s mother having a history of breast cancer. A family history of breast cancer in primary female relatives, such as a mother, does increase the risk for male breast cancer. Rationale 3: History of cirrhosis of the liver. Cirrhosis of the liver has been found to increase the risk for male breast cancer. Rationale 4: History of kidney disease. A history of kidney disease is not a predisposing factor for male breast cancer. Rationale 5: History of radiation treatment for lung cancer. Radiation exposure, such as radiation therapy for lung cancer, increases the risk for male breast cancer. Global Rationale: Predisposing factors for breast cancer in the male population include radiation exposure, cirrhosis, estrogen medications, and a history of breast cancer in primary female relatives. Taking testosterone and kidney disease are not predisposing factors for male breast cancer. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 16.2: Develop questions to be used when completing the focused interview. Question 28 Type: MCSA During the focused assessment of a female client, she reports breast tenderness, swelling, and lymph node enlargement around the time of her period. The nurse’s best response to this finding is: 1. “This sounds like a condition known as nodularity. It is a benign disorder so you will need to monitor your breasts monthly.” 2. “Fluctuating hormone levels around the time of your period frequently causes these symptoms. I will note this in your chart and notify your primary care provider.” 3. “As long as you have not detected any lumps you have nothing to worry about.” 4. “Do you have a history of fibrocystic breast disease? These symptoms are usually seen with this disease.” Correct Answer: 2 Rationale 1: Nodularity is a benign physiologic condition of lumps in the breasts that occur just prior to the menstrual period through the end of the period. The client in this scenario does not report any lumps. Rationale 2: Fluctuating hormone levels frequently cause these symptoms, along with breast pain. Contraceptives can also cause these symptoms. The nurse is also correct in documenting the symptoms and informing the primary care provider so that further evaluation can occur. Rationale 3: “As long as you have not detected any lumps you have nothing to worry about,” does not validate the information the client is reporting, nor does it help to tell the client not to worry. In addition, this response may lead the client to believe that only lumps would be of significance to report. Rationale 4: While fibrocystic breast disease frequently coincides with fluctuating hormone levels of menstruation, its symptoms vary in that along with painful breasts, the client will have masses upon palpation that feel soft, well demarcated, and freely movable. These masses are usually found bilaterally. Clear, straw colored, milky, or green discharge from the nipples may also occur. Global Rationale: “Fluctuating hormone levels around the time of your period frequently causes these symptoms. I will note this in your chart and notify your primary care provider” is the best response since these are typical symptoms associated with the fluctuation of hormone levels during menses, but should still be reported. Nodularity is a benign condition, but the client does not mention any nodules being present. Stating “As long as you have not detected any lumps you have nothing to worry about,” may lead the client to feel that complaints are not justified unless lumps are present. Fibrocystic breast disease is seen with fluctuation of hormone levels with menses but typically has several other symptoms in addition to breast pain, including bilateral masses upon palpation that feel soft, well demarcated, and freely movable, and clear, straw colored, milky, or green discharge from the nipples. Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.2: Develop questions to be used when completing the focused interview. Question 29 Type: MCMA While the nurse is performing an assessment of a male client, gynecomastia is noted. The nurse is aware that this condition is most frequently associated with: Standard Text: Select all that apply. 1. cancer of the breast in male clients. 2. infants following birth. 3. the onset of puberty. 4. older males that have undergone hormonal treatment. 5. infection of breast tissue. Correct Answer: 2,3,4 Rationale 1: Cancer of the breast in male clients. Cancer of the breast in males typically manifests as a hard nodule fixed to the nipple and underlying tissue, and nipple discharge may be present. Breast enlargement is not a typical symptom of breast cancer in males. Rationale 2: Infants following birth. Gynecomastia is a temporary condition of breast enlargement in males, and is commonly seen in infants following birth. Rationale 3: The onset of puberty. Gynecomastia is a temporary condition of breast enlargement in males that is sometimes seen at the onset of puberty, and may occur in one or both breasts. Rationale 4: Older males that have undergone hormonal treatment. Gynecomastia is a temporary condition of breast enlargement in males that may be seen in older adult males; especially those that have received hormonal treatment for prostate cancer. Rationale 5: Infection of breast tissue. Infection of breast tissue is not generally associated with gynecomastia. Global Rationale: Gynecomastia is a temporary condition of breast enlargement in males. It is most commonly seen in infants, at puberty, and in older males. In older males it may accompany hormonal treatment for prostate cancer. Cancer of the breast in males typically manifests as a hard nodule fixed to the nipple and underlying tissue, and nipple discharge may be present. Gynecomastia is not associated with infection of the breast. Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae. Question 30 Type: MCSA A female client asks the nurse when the best time is to perform self-breast examination (SBE). The nurse’s best response is: 1. “If you are still menstruating the best time is about 5 days after your period begins each month.” 2. “If you are postmenopausal the best time is at the beginning of each month.” 3. “It doesn’t really matter as long as you keep a record of when you perform the exam.” 4. “Your primary care provider can tell you when the best time is for you.” Correct Answer: 1 Rationale 1: “If you are still menstruating the best time is about 5 days after your period begins each month,” is the best response since there is less hormonal influences on the breast tissue at this time, and it provides a consistent timetable for SBE. Rationale 2: “If you are postmenopausal the best time is at the beginning of each month,” is an inaccurate statement. There is no benefit to performing SBE at the beginning of each month, as long as the client performs SBE at the same time each month. Rationale 3: “It doesn’t really matter as long as you keep a record of when you perform the exam,” is an inaccurate statement. The client should perform SBE at the same time each month for consistency. Rationale 4: “Your primary care provider can tell you when the best time is for you” is an inaccurate statement since it is not necessary for the primary care provider to set a schedule for the client to perform SBE. Global Rationale: For females who are still menstruating, 5 days after the period begins is the best time to perform SBE on a monthly basis since there is less hormonal influences on the breast tissue at this time, and it provides a consistent timetable for SBE. If the female is postmenopausal there is no benefit to performing SBE at the beginning of each month, as long as she performs SBE at the same time each month. It is not necessary for the primary care provider to set a schedule for the client to perform SBE. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of female breasts.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 17 Question 1 Type: MCSA The nurse who works on a cardiac unit is teaching the student nurse about heart sounds. The student nurse asks how the S1 heart sound is produced. Which of the following is the nurse’s best response? 1. “It results from the closure of the semilunar valves.” 2. “It is heard when the aortic valve closes just slightly faster than the pulmonic valve.” 3. “It results from the closure of the atrioventricular valves.” 4. “It is caused by atrial contraction and ejection of blood into the ventricles in late diastole.” Correct Answer: 3 Rationale 1: The S2 sounds results from the closure of the semilunar valves. The semilunar valves include the aortic and pulmonic valves. Rationale 2: A splitting of the S2 occurs toward the end of inspiration in some individuals. This results from a slight difference between the time the aortic and pulmonic valves close. Rationale 3: The S1 heart sound results from closure of the atrioventricular (AV) valves. Rationale 4: The S4 sound may be heard in children, well-conditioned athletes, and healthy elderly individuals without cardiac disease. It is caused by atrial contraction and ejection of blood into the ventricles in late diastole. Global Rationale: The S2 sounds results from the closure of the semilunar valves. The semilunar valves include the aortic and pulmonic valves. A splitting of the S2 occurs toward the end of inspiration in some individuals. This results from a slight difference between the time the aortic and pulmonic valves close. The S1 heart sound results from closure of the atrioventricular (AV) valves. The S4 sound may be heard in children, well-conditioned athletes, and healthy elderly individuals without cardiac disease. It is caused by atrial contraction and ejection of blood into the ventricles in late diastole. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.1: Identify the anatomy and physiology of the cardiovascular system. Question 2 Type: HOTSPOT

The client’s healthcare provider determines that the client’s left ventricle is functioning adequately. Identify the left ventricle by drawing an arrow to it.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : Global Rationale: Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.1: Identify the anatomy and physiology of the cardiovascular system.

Question 3 Type: FIB The client’s stroke volume is 72 ml/beat. The client’s heart rate is 82 beats per minute. What is the client’s cardiac output? Standard Text: Correct Answer: 5904 mL per minute. Rationale: Stroke volume describes the amount of blood that is ejected with every heartbeat. Normal stroke volume is 55 to 100 ml/beat. Cardiac output describes the amount of blood ejected from the left ventricle over 1 minute. Normal adult cardiac output is 4 to 8 liters per minute. The formula for calculating cardiac output is: cardiac output = stroke volume multiplied by heart rate for 1 minute. 72 ml/ beat x 82 beats/ minute= 5904 mL/ minute Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.1: Identify the anatomy and physiology of the cardiovascular system. Question 4 Type: HOTSPOT The nurse is performing a cardiac assessment and prepares to palpate the client’s heartbeat on the client’s chest. Draw an arrow pointing to this area.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The point of maximal impulse or PMI is located at the fifth intercostal space at the midclavicular line. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2: Recognize landmarks that guide assessment of the cardiovascular system. Question 5 Type: HOTSPOT The nurse is reviewing the client’s chart. The client’s blood pressure has been consistently elevated over the last eight years. The client has been noncompliant with lifestyle changes and medication use designed to reduce the client’s blood pressure. Today, the nurse is able to palpate a heave on the client’s chest. Draw an arrow to the most likely location that the nurse is able to palpate the heave.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : Pulsations or heaves palpated at the right sternal border in the second intercostal space are associated with systemic hypertension. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.2: Recognize landmarks that guide assessment of the cardiovascular system. Question 6 Type: MCMA During the focused interview, the client answers the nurse’s questions. Which of the following statements by the client suggests that the client has an increased risk of developing cardiovascular disease? Standard Text: Select all that apply. 1. “I have been stressed out since my divorce last year.” 2. “I’m what you call a Type C personality.” 3. “I went on this new diet because I gained 30 pounds in the last 9 months.” 4. “On my new diet, I can eat only grains and vegetables.” 5. “I think about my job all of the time.” Correct Answer: 1,3,4,5 Rationale 1: “I have been stressed out since my divorce last year.” Psychosocial problems and excessive stress can increase the client’s risk for developing cardiovascular disease. Rationale 2: “I’m what you call a Type C personality.” Type A personalities tend to develop cardiovascular disease more often than people with other personality types.

Rationale 3: “I went on this new diet because I gained 30 pounds in the last 9 months.” Obesity and a high percentage of body fat are risk factors for cardiovascular disease. Weight gain may accompany physical problems including systemic diseases such as diabetes, which increases this client’s risk for developing cardiovascular disease. Rationale 4: “On my new diet, I can eat only grains and vegetables.” The nurse must note if the client has been dieting to reduce weight. Many diets deplete valuable electrolytes and subject the client to potential complications. Muscle wasting may occur if the diet is deficient in protein. Lack of protein may compromise cardiac function. Rationale 5: “I think about my job all of the time.” Stress increases the stimulation of the client’s sympathetic nervous system and can increase the client’s risk for developing cardiovascular disease. Global Rationale: Psychosocial problems and excessive stress can increase the stimulation of the client’s sympathetic nervous system, thereby increasing the client’s risk for developing cardiovascular disease. Type A personalities tend to develop cardiovascular disease more often than people with other personality types. Obesity and a high percentage of body fat are risk factors for cardiovascular disease. Weight gain may accompany physical problems including systemic diseases such as diabetes, which increases this client’s risk for developing cardiovascular disease. The nurse must note if the client has been dieting to reduce weight. Many diets deplete valuable electrolytes and subject the client to potential complications. Muscle wasting may occur if the diet is deficient in protein. Lack of protein may compromise cardiac function. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.3: Develop questions to be used when completing the focused interview. Question 7 Type: MCSA 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. “I was diagnosed with hypothyroidism about 5 years ago.” 2. “My doctor always tells me when I come in that my blood pressure is low.” 3. “I know my grandmother had diabetes, but every time it has been checked mine has been normal.” 4. “My total cholesterol has always been around 170.” Correct Answer: 1 Rationale 1: Hypothyroidism may increase the client’s risk for developing cardiovascular disease. Rationale 2: Hypertension, not hypotension, is associated with the development of cardiovascular disease.

Rationale 3: Normal serum glucose levels indicate that the client does not currently have diabetes and so this client’s risk is not necessarily increased. Rationale 4: The client’s total cholesterol level is within normal limits. High cholesterol levels would increase the client’s risk for developing cardiovascular disease. Global Rationale: Hypothyroidism may increase the client’s risk for developing cardiovascular disease. Hypertension, not hypotension, is associated with the development of cardiovascular disease. Normal serum glucose levels indicate that the client does not currently have diabetes and so this client’s risk is not necessarily increased. The client’s total cholesterol level is within normal limits. High cholesterol levels would increase the client’s risk for developing cardiovascular disease. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.3: Develop questions to be used when completing the focused interview. Question 8 Type: MCSA The nurse is performing a focused interview with an adult male client who recently experienced a myocardial infarction. The nurse requests information about how he felt during the time of the myocardial infarction. Which of the following client statements would be unexpected? 1. “I couldn’t catch my breath.” 2. “My chest didn’t actually ever hurt.” 3. “My wife said I looked like someone poured water all over me.” 4. “I got so sick to my stomach.” Correct Answer: 2 Rationale 1: Typically males who are experiencing a myocardial infarction will complain of dyspnea. Rationale 2: Typically males who are experiencing a myocardial infarction will complain of chest pain that is prolonged, dull, and radiates to the shoulder or jaw. Females are more likely to experience nausea and vomiting, indigestion, shortness of breath or extreme fatigue, without actual chest pain. Rationale 3: In males, the pain of MI is often accompanied by diaphoresis. Rationale 4: In males, the pain of MI is often accompanied by nausea. Global Rationale: Typically males who are experiencing a myocardial infarction will complain of dyspnea, and chest pain that is prolonged, dull, and radiates to the shoulder or jaw. In males, the pain is often accompanied by

diaphoresis and they may complain of nausea. Females are more likely to experience nausea and vomiting, indigestion, shortness of breath or extreme fatigue, without actual chest pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.3: Develop questions to be used when completing the focused interview. Question 9 Type: MCSA The nurse is interviewing a client who has recently been diagnosed with atherosclerosis in the client’s coronary arteries. Which of the following questions by the nurse has the highest priority to help the nurse determine the client’s most important risk factor for this condition? 1. “Can you please tell me about the vitamins or supplements that you take?” 2. “Have you ever been diagnosed with rheumatic fever?” 3. “Do you smoke or are you exposed to secondhand smoke?” 4. “Have you ever had a diagnostic test, such as an electrocardiogram, stress test, or echocardiogram, or a surgical procedure for a cardiovascular problem?” Correct Answer: 3 Rationale 1: Information about vitamin and supplement use is important but is not specifically related to atherosclerosis and coronary artery disease. Rationale 2: A history of rheumatic fever can increase the client’s risk for valvular problems but does not necessarily increase the client’s risk for developing atherosclerosis and coronary artery disease. Rationale 3: The most important question regarding this client’s history and recent diagnosis is about exposure to cigarettes smoke. The chemical contained in the cigarette smoke injures the inner wall of arterial vessels and contributes to the subsequent development of a coronary artery plaque. Rationale 4: Diagnostic testing may help the nurse determine if there was a previous suspicion that the client had developed a cardiovascular problem, but is not specifically related to coronary artery disease and atherosclerosis. Global Rationale: Information about vitamin and supplement use is important but is not specifically related to atherosclerosis and coronary artery disease. A history of rheumatic fever can increase the client’s risk for valvular problems but does not necessarily increase the client’s risk for developing atherosclerosis and coronary artery disease. The most important question regarding this client’s history and recent diagnosis is about exposure to cigarettes smoke. The chemical contained in the cigarette smoke injures the inner wall of arterial vessels and contributes to the subsequent development of a coronary artery plaque. The question regarding diagnostic testing may help the nurse determine if there was a previous suspicion that the client had developed a cardiovascular problem, but is not specifically related to coronary artery disease and atherosclerosis.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.3: Develop questions to be used when completing the focused interview. Question 10 Type: MCMA The nurse is preparing to assess the female client’s cardiovascular system during the client’s visit to the healthcare provider’s office. Which of the following items should the nurse have available in the room in order to complete the examination? Standard Text: Select all that apply. 1. Ruler (metric) 2. Stethoscope 3. Lamp 4. Client gown and a drape 5. Doppler Correct Answer: 1,2,3,4,5 Rationale 1: Ruler (metric). The nurse will require a metric ruler to determine distention of blood vessels. Rationale 2: Stethoscope. The nurse will require a stethoscope to auscultate the client’s heart and arteries. Rationale 3: Lamp. The nurse will require a lamp or adequate lighting in the room for the inspection process of the assessment. Rationale 4: Client gown and a drape. Female clients should be provided with a gown and a drape for this examination in order to maintain privacy and avoid overexposure. Rationale 5: Doppler. A Doppler device can be used to determine the presence of a pulse if the nurse is unable to adequately palpate the pulse. Global Rationale: The nurse will require a metric ruler to determine distention of blood vessels. The nurse will require a stethoscope to auscultate the client’s heart and arteries. The nurse will require a lamp or adequate lighting in the room for the inspection process of the assessment. Female clients should be provided with a gown and a drape for this examination in order to maintain privacy and avoid overexposure. A Doppler device can be used to determine the presence of a pulse if the nurse is unable to adequately palpate the pulse. Cognitive Level: Remembering

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.4: Explain client preparation for assessment of the cardiovascular system. Question 11 Type: MCMA The nurse is preparing to assess the client’s cardiovascular system. Which of the following positions will the nurse need to place the client in during the assessment? Standard Text: Select all that apply. 1. Dorsal recumbent 2. Leaning forward 3. Right lateral position 4. Left lateral position 5. Sitting upright Correct Answer: 1,2,4,5 Rationale 1: Dorsal recumbent. The client will be asked to remain in a supine position or dorsal recumbent position for part of the examination. The nurse may be able to auscultate murmurs better while the client is in this position. Rationale 2: Leaning forward. The client will be asked to lean forward during auscultation of the heart. The nurse should listen to the client’s heart while the client is leaning forward. Rationale 3: Right lateral position. This is not a common position to place the client in during this type of examination. Rationale 4: Left lateral position. The client will be asked to lie on the left side during part of this examination. In obese clients, heart sounds are best heard at the apical area with the client in the left lateral position. Rationale 5: Sitting upright. The nurse will most likely begin this examination while the client is in this position. This is the position the nurse should ask the client to assume when beginning chest auscultation. Global Rationale: The nurse will most likely begin this examination with the client sitting upright. This is the position the nurse should ask the client to assume when beginning chest auscultation. The client will be asked to remain in a supine position or dorsal recumbent position for part of the examination. The nurse may be able to auscultate murmurs better while the client is in this position. The client will be asked to lean forward during auscultation of the heart. The nurse should listen to the client’s heart while the client is leaning forward. The client will be asked to lie on the left side during part of this examination. In obese clients, heart sounds are best

heard at the apical area with the client in the left lateral position. Right lateral position is not a common position to place the client in during this type of examination. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.4: Explain client preparation for assessment of the cardiovascular system. Question 12 Type: SEQ The nurse is preparing to perform a cardiac assessment on a client. Rank the following pieces of the assessment in order of occurrence. Standard Text: Click and drag the options below to move them up or down. Choice 1. Auscultation of the client’s heart, apical pulse, and carotid arteries Choice 2. Inspection of the client’s head and neck, chest, abdomen, and extremities Choice 3. Percussion of the client’s chest Choice 4. Palpation of the precordium and pulses Correct Answer: 2,4,3,1 Rationale 1: The fourth of these steps is auscultation. Auscultation includes the heart in five areas with the diaphragm and the bell of the stethoscope. The carotid arteries and the apical pulse are auscultated. Rationale 2: The first of these steps is inspection of the client’s head and neck. The upper extremities, chest, abdomen, and lower extremities are also inspected. Rationale 3: The third of these steps is percussion, which is conducted to determine the cardiac borders. Rationale 4: The second of these steps is palpation. Palpation includes the precordium and carotid pulses. Global Rationale: Physical assessment of the cardiovascular system follows an organized pattern. It begins with inspection of the client’s head and neck. The upper extremities, chest, abdomen, and lower extremities are also inspected. Palpation includes the precordium and carotid pulses. Percussion of the chest is conducted to determine the cardiac borders. Auscultation includes the heart in five areas with the diaphragm and the bell of the stethoscope. The carotid arteries and the apical pulse are auscultated. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5: Describe the techniques required for assessment of the cardiovascular system.

Question 13 Type: MCMA 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? Standard Text: Select all that apply. 1. The client complains of discomfort while lying flat. The student nurse auscultates the client’s chest quickly while the client continues to lie flat. 2. The student nurse determines that the apical impulse is located at the fifth intercostal space at the midclavicular line. 3. The student nurse examines the client’s legs and notes that the client’s hair is evenly distributed. 4. The student nurse gently palpates the client’s carotid arteries simultaneously to determine pulse strength, rhythm, and rate. 5. The student nurse examines the client’s hands and fingers and notes the presence of clubbing. Correct Answer: 1,4 Rationale 1: The client complains of discomfort while lying flat. The student nurse auscultates the client’s chest quickly while the client continues to lie flat. If the client complains of any discomfort during the examination, the nurse should pause the examination and the client should be assisted into a more comfortable position for the rest of the examination. Not all clients will be able to assume every position associated with this examination. Rationale 2: The student nurse determines that the apical impulse is located at the fifth intercostal space at the midclavicular line. This is normally where the point of maximal impulse can be palpated. Rationale 3: The student nurse examines the client’s legs and notes that the client’s hair is evenly distributed. This is an appropriate part of the examination. Patchy hair distribution can indicate that there is a circulatory problem. Rationale 4: The student nurse gently palpates the client’s carotid arteries simultaneously to determine pulse strength, rhythm, and rate. The carotid pulses must never be palpated simultaneously since this may obstruct blood flow to the brain, resulting in severe bradycardia or asystole. Rationale 5: The student nurse examines the client’s hands and fingers and notes the presence of clubbing. It is appropriate to examine the client’s hands and fingers to determine the existence of peripheral circulatory problems. Global Rationale: If the client complains of any discomfort during the examination, the nurse should pause the examination and the client should be assisted into a more comfortable position for the rest of the examination. Not all clients will be able to assume every position associated with this examination. If the student nurse has determined the apical impulse to be located at the fifth intercostal space at the midclavicular line, this is normal.

Examining the client’s legs and noting that the client’s hair is evenly distributed is an appropriate part of the examination. Patchy hair distribution can indicate that there is a circulatory problem. The carotid pulses must never be palpated simultaneously since this may obstruct blood flow to the brain, resulting in severe bradycardia or asystole. It is appropriate to examine the client’s hands and fingers to determine the existence of peripheral circulatory problems. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5: Describe the techniques required for assessment of the cardiovascular system. Question 14 Type: HOTSPOT The client has a history of rheumatic fever. Draw an arrow pointing to the layer of the heart that is most at risk for damage due to this infection.

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : Strep infections can cause rheumatic fever. Rheumatic fever can damage the client’s endocardium. The endocardium makes up the innermost layer of the heart and valve tissue. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment. Question 15 Type: MCSA 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 developed a murmur. 4. The client has a pulse deficit. Correct Answer: 2 Rationale 1: This is not a normal finding. When the nurse percusses over lung tissue, the sound should be described as resonant. Rationale 2: An enlarged heart emits a dull sound on percussion over a larger area than a heart of normal size. Rationale 3: Murmurs can be determined during auscultation of the heart. Rationale 4: A pulse deficit is present when the apical pulse is greater than the carotid pulse. Global Rationale: This is not a normal finding. When the nurse percusses over lung tissue, the sound should be described as resonant. An enlarged heart emits a dull sound on percussion over a larger area than a heart of normal size. Murmurs can be determined during auscultation of the heart. A pulse deficit is present when the apical pulse is greater than the carotid pulse. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment. Question 16

Type: MCSA The nurse is performing a cardiac assessment on a 70-year-old client admitted with hypertension. The nurse determines that the apical impulse can be palpated in an area 2 cm in diameter at the point of maximal impulse. The nurse suspects that the client may have developed which of the following problems? 1. Left ventricular hypertrophy 2. Aortic stenosis 3. Right ventricular volume overload 4. Enlarged left atrium Correct Answer: 1 Rationale 1: If the apical impulse can be palpated in an area greater than 1 cm in diameter or is laterally displaced, the conditions that may be present include left ventricular hypertrophy, severe left ventricular volume overload, or severe aortic regurgitation. Rationale 2: Clients with aortic stenosis often have heaves present at the right sternal border, second intercostal space. Rationale 3: The presence of heaves or thrills in the subxiphoid area suggests the presence of right ventricular volume overload. Rationale 4: Pulsations or heaves in the left sternal border, second intercostal space, are associated with an enlarged left atrium. Global Rationale: If the apical impulse can be palpated in an area greater than 1 cm in diameter or is laterally displaced, the conditions that may be present include left ventricular hypertrophy, severe left ventricular volume overload, or severe aortic regurgitation. Clients with aortic stenosis often have heaves present at the right sternal border, second intercostal space. The presence of heaves or thrills in the subxiphoid area suggests the presence of right ventricular volume overload. Pulsations or heaves in the left sternal border, second intercostal space, are associated with an enlarged left atrium. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment. Question 17 Type: MCSA A 39-year-old client has been admitted to the hospital with complaints of increasing fatigue. The history is remarkable for rheumatic fever as a child. The nurse hears a diastolic murmur at the apex when the client is in the

left lateral position. The murmur is described as a rumble without radiation. This description is most consistent with: 1. tricuspid regurgitation. 2. mitral regurgitation. 3. mitral stenosis. 4. pulmonic stenosis. Correct Answer: 3 Rationale 1: The murmur associated with tricuspid regurgitation is often described as systolic, blowing, highpitched, and may radiate. Rationale 2: Mitral regurgitation is a high-pitched, blowing, harsh, systolic murmur with radiation to the left axilla. Rationale 3: The murmur associated with mitral stenosis is best heard with the bell of the stethoscope at the apex while the client is placed in the left lateral position. It is a low-frequency diastolic murmur, which does not radiate. It is often caused by rheumatic fever or a cardiac infection. Rationale 4: The murmur associated with pulmonic stenosis is often described as a harsh, systolic murmur heard best over the pulmonic area with radiation to the neck. Global Rationale: The murmur associated with tricuspid regurgitation is often described as systolic, blowing, high-pitched, and may radiate. Mitral regurgitation is a high-pitched, blowing, harsh, systolic murmur with radiation to the left axilla. The murmur associated with mitral stenosis is best heard with the bell of the stethoscope at the apex while the client is placed in the left lateral position. It is a low-frequency diastolic murmur, which does not radiate. It is often caused by rheumatic fever or a cardiac infection. The murmur associated with pulmonic stenosis is often described as a harsh, systolic murmur heard best over the pulmonic area with radiation to the neck. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment. Question 18 Type: MCSA During the cardiac assessment of a client, the nurse hears a loud rumbling during diastole that increases toward the end of the sound. This sound is heard with the bell of the stethoscope over the lower left sternal border. The nurse would suspect which of the following in this client? 1. Aortic stenosis

2. Tricuspid stenosis 3. Mitral regurgitation 4. Pulmonic stenosis Correct Answer: 2 Rationale 1: The type of murmur heard with aortic stenosis occurs midsystole and is crescendo-decrescendo. Rationale 2: The sound heard in this scenario is most likely a murmur related to tricuspid stenosis. Tricuspid stenosis may produce a loud rumbling sound during diastole. The sound increases towards the end of the sound. Rationale 3: With mitral regurgitation, the sound is heard in systole and is continuous. Rationale 4: With pulmonary stenosis, the midsystolic sound is heard over the right sternal border in the second intercostal space. Global Rationale: The type of murmur heard with aortic stenosis occurs midsystole and is crescendodecrescendo. The sound heard in this scenario is most likely a murmur related to tricuspid stenosis. Tricuspid stenosis may produce a loud rumbling sound during diastole. The sound increases toward the end of the sound. With mitral regurgitation, the sound is heard in systole and is continuous. With pulmonary stenosis, the midsystolic sound is heard over the right sternal border in the second intercostal space. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment. Question 19 Type: MCSA The Intensive Care Unit nurse is performing a cardiac assessment on a newly admitted 72-year-old client and notes the following findings: peripheral edema, jugular venous distention of 5 cm above the sternal angle when the client is at a 45 degree angle, and an enlarged liver. These findings are most consistent with which of the following disorders? 1. Pulmonary edema 2. Left-sided heart failure 3. Myocardial infarction 4. Right-sided heart failure Correct Answer: 4

Rationale 1: Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system. Rationale 2: Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system. Rationale 3: Heart failure may be caused by a myocardial infarction. However, the clinical manifestations associated with heart failure are not always the result of a myocardial infarction. Rationale 4: With right-sided heart failure, the right ventricle is ineffective as a pump, which leads to congestion as blood backs up into the systemic circulation. Right-sided heart failure results in increased jugular vein distention. This is a reflection of the increased pressure in the right atrium. Right-sided heart failure also results in peripheral edema and liver enlargement. Global Rationale: Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system. Heart failure may be caused by a myocardial infarction. However, the clinical manifestations associated with heart failure are not always the result of a myocardial infarction. With right-sided heart failure, the right ventricle is ineffective as a pump, which leads to congestion as blood backs up into the systemic circulation. Right-sided heart failure results in increased jugular vein distention. This is a reflection of the increased pressure in the right atrium. Right-sided heart failure also results in peripheral edema and liver enlargement. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment. Question 20 Type: MCSA The nurse is assessing a client and notes a loud, blowing sound over the right carotid artery. The nurse would suspect the client has developed which of the following disorders? 1. Mitral stenosis 2. Aortic regurgitation 3. Atrial septal defect 4. Stricture of the carotid Correct Answer: 4 Rationale 1: Mitral stenosis is a narrowing of the left mitral valve. In a client with mitral stenosis, there is often a murmur heard at the apical area with the client in left lateral position.

Rationale 2: Aortic regurgitation is the backflow of blood from the aorta into the left ventricle. With aortic regurgitation, a murmur may be heard when the client is leaning forward, at the second intercostal space. Rationale 3: With an atrial septal defect, there is an opening between the right and left atrium. Regurgitation occurs through this defect resulting in a harsh, loud, high-pitched murmur heard at the left sternal border at the second intercostal space. Rationale 4: A bruit, which is a loud swishing or blowing sound, is most often associated with a narrowing or stricture of the carotid artery. The most common cause for this is atherosclerosis. Global Rationale: Mitral stenosis is a narrowing of the left mitral valve. In a client with mitral stenosis, there is often a murmur heard at the apical area with the client in left lateral position. Aortic regurgitation is the backflow of blood from the aorta into the left ventricle. With aortic regurgitation, a murmur may be heard when the client is leaning forward, at the second intercostal space. With an atrial septal defect, there is an opening between the right and left atrium. Regurgitation occurs through this defect resulting in a harsh, loud, high-pitched murmur heard at the left sternal border at the second intercostal space. A bruit, which is a loud swishing or blowing sound, is most often associated with a narrowing or stricture of the carotid artery. The most common cause for this is atherosclerosis. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment. Question 21 Type: MCMA The nurse is caring for a client admitted with a grade 3 heart murmur heard during systole. The nurse would suspect which of the following cardiac conditions? Standard Text: Select all that apply. 1. Mitral regurgitation 2. Mitral stenosis 3. Aortic stenosis 4. Pulmonic stenosis 5. Tricuspid stenosis Correct Answer: 1,3,4 Rationale 1: Mitral regurgitation. A grade 3 murmur can be heard clearly and the nurse should be able to categorize the murmur easily. The murmur associated with mitral regurgitation can be heard during systole.

Rationale 2: Mitral stenosis. The murmur associated with mitral stenosis can be heard during diastole. Rationale 3: Aortic stenosis. Midsystolic murmurs are associated with semilunar valve disorders. This murmur is heard during midsystole and this can be associated with aortic stenosis. Rationale 4: Pulmonic stenosis. Midsystolic murmurs are associated with semilunar valve disorders. This murmur is heard during midsystole and this can be associated with pulmonic stenosis. Rationale 5: Tricuspid stenosis. The murmur associated with tricuspid stenosis can be heard during diastole. Global Rationale: The murmur associated with mitral regurgitation can be heard during systole. Midsystolic murmurs are associated with semilunar valve disorders. This murmur is heard during midsystole and this can be associated with pulmonic or aortic stenosis. The murmur associated with mitral or tricusid stenosis can be heard during diastole. The murmur associated with tricuspid stenosis can be heard during diastole. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment. Question 22 Type: MCMA 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? Standard Text: Select all that apply. 1. Refer the client to a plastic surgeon. 2. Document this finding as normal. 3. Document the finding and notify the healthcare provider. 4. Ask the client about any history of injuries to his ears. 5. Assess the client’s risk factors for coronary artery disease. Correct Answer: 3,4,5 Rationale 1: Refer the client to a plastic surgeon. The client may have an increased risk for developing coronary artery disease. At this point, the client does not need to be referred to a plastic surgeon. Rationale 2: Document this finding as normal. This is an abnormal finding and the client should be carefully monitored for the development of coronary artery disease.

Rationale 3: Document the finding and notify the healthcare provider. The nurse should document the finding, request information from the client regarding any injuries to the ears, and notify the healthcare provider about the presence of the bilateral earlobe creases. Rationale 4: Ask the client about any history of injuries to his ears. The nurse should determine if the client has sustained any injuries to the ears that could account for the bilateral earlobe creases. Rationale 5: Assess the client’s risk factors for coronary artery disease. The nurse should assess the client for any other clinical manifestations and risk factors associated with coronary artery disease. Global Rationale: This is an abnormal finding and the client should be carefully monitored for the development of coronary artery disease. The nurse should document the finding, request information from the client regarding any injuries to the ears, and notify the healthcare provider about the presence of the bilateral earlobe creases. The nurse should assess the client for any other clinical manifestations and risk factors associated with coronary artery disease. At this point, the client does not need to be referred to a plastic surgeon. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment. Question 23 Type: MCMA The nurse is performing a cardiac assessment on a healthy elderly adult client. Which of the following findings may be expected when compared to when the client was middle-aged? Standard Text: Select all that apply. 1. Systolic murmur 2. Increased cardiac output 3. Increased systolic blood pressure 4. Increased stroke volume 5. Slight decrease in heart rate Correct Answer: 1,3,4,5 Rationale 1: Systolic murmur. Systolic murmurs become more common as people age, especially because of aortic stenosis. Rationale 2: Increased cardiac output. In the healthy older adult, cardiac output remains relatively stable. Rationale 3: Increased systolic blood pressure. The client’s systolic blood pressure may increase.

Rationale 4: Increased stroke volume. Stroke volume may increase slightly when the client is at rest and during exercise. Rationale 5: light decrease in heart rate. The healthy older adult may have an insignificant decrease in heart rate. Global Rationale: Systolic murmurs become more common as people age, especially because of aortic stenosis. In the healthy older adult, cardiac output remains relatively stable. The older client’s systolic blood pressure may increase. Stroke volume may increase slightly when the older client is at rest and during exercise. The healthy older adult may have an insignificant decrease in heart rate. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 24 Type: MCSA The nurse is assessing a client who is 7 months pregnant. The nurse would document which of the following cardiac findings as normal in this client? 1. Increased systolic and diastolic blood pressures when standing 2. Point of maximal impulse palpated at fourth intercostal space and left of midclavicular line 3. Bradycardia 4. Diastolic murmur Correct Answer: 2 Rationale 1: At this stage of the client’s pregnancy, the blood pressure should be normal when compared to prepregnancy values. Rationale 2: During pregnancy, the heart is displaced to the left and upward and so it would be normal to palpate the point of maximal impulse left of the midclavicular line at the fourth intercostal space. Rationale 3: The pregnancy usually results in an increase in the client’s heart rate from pre-pregnancy values. Rationale 4: It is not normal to find a diastolic murmur. Global Rationale: At this stage of the client’s pregnancy, the blood pressure should be normal when compared to pre-pregnancy values. During pregnancy, the heart is displaced to the left and upward and so it would be normal to palpate the point of maximal impulse left of the midclavicular line at the fourth intercostal space. The

pregnancy usually results in an increase in the client’s heart rate from pre-pregnancy values. It is not normal to find a diastolic murmur. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 25 Type: MCSA The nurse is assessing a full-term African American newborn that is 18 hours old. The nurse would document which of the following as a normal finding? 1. Lethargy 2. Heart rate 115–120 3. Bulging of the precordium 4. Pale conjunctiva Correct Answer: 2 Rationale 1: The infant should be easily aroused and alert. Rationale 2: The heart rate of a newborn initially may be as high as 175–180 beats per minute but should decrease over the next 6 to 8 hours to about 115–120 beats per minute. Rationale 3: Precordial bulging should always be evaluated and is never considered a normal finding. Rationale 4: The skin should demonstrate perfusion with pink quality in the nail beds, mucous membranes, and conjunctiva regardless of the baby’s race. Global Rationale: The infant should be easily aroused and alert. The heart rate of a newborn initially may be as high as 175–180 beats per minute but should decrease over the next 6 to 8 hours to about 115–120 beats per minute. Precordial bulging should always be evaluated and is never considered a normal finding. The skin should demonstrate perfusion with pink quality in the nail beds, mucous membranes, and conjunctiva regardless of the baby’s race. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 26 Type: MCSA The nurse notes the pregnant client’s blood pressure has dropped from 122/70 taken during her second month of pregnancy to 118/64 during her fifth month of pregnancy. Which of the following actions by the nurse is most appropriate? 1. Assess for signs of hemorrhage. 2. Document the blood pressure as a normal finding . 3. Consult the healthcare provider. 4. Tell the client to come in the next day so the nurse can recheck her blood pressure. Correct Answer: 2 Rationale 1: This small drop in blood pressure is expected and the nurse does not need to assess the client for signs of hemorrhage. Rationale 2: During pregnancy, there is a substantial increase in cardiac workload secondary to the increase in blood volume. Despite this, the systolic and diastolic blood pressures may decrease during the first half of pregnancy. This is secondary to the peripheral vasodilatation. During the second half of the pregnancy, the blood pressure will return to previous pre-pregnancy levels. Rationale 3: The healthcare provider does not need to be consulted because this is a normal finding. Rationale 4: The client does not need to return to have her blood pressure checked on the following day. Global Rationale: This small drop in blood pressure is expected and the nurse does not need to assess the client for signs of hemorrhage. During pregnancy, there is a substantial increase in cardiac workload secondary to the increase in blood volume. Despite this, the systolic and diastolic blood pressures may decrease during the first half of pregnancy. This is secondary to the peripheral vasodilatation. During the second half of the pregnancy, the blood pressure will return to previous pre-pregnancy levels. The healthcare provider does not need to be consulted because this is a normal finding. The client does not need to return to have her blood pressure checked on the following day. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 27 Type: MCSA

The student nurse is speaking with a nurse regarding the objectives of Healthy People 2020. Which of the following statements by the student nurse indicates that the student nurse requires further education regarding these objectives? 1. “Parents of school-aged children really need to be educated about the importance of treating strep throat.” 2. “African Americans really need to be educated about the symptoms associated with hypertension.” 3. “People who smoke are twice as likely to die from a heart attack when compared to those who don’t smoke.” 4. “African Americans can benefit greatly from education aimed at increasing their understanding about the importance of exercise.” Correct Answer: 2 Rationale 1: It is appropriate to educate parents of school-aged children about the importance of screening for and treating strep in their children. This can help prevent rheumatic fever and the valvular problems that are associated with this infection. Rationale 2: African Americans can benefit from blood pressure screening activities. Hypertension is often present without any symptoms so education about symptoms will not be particularly beneficial. Rationale 3: Smokers have double the mortality rate from myocardial infarction than nonsmokers. Rationale 4: The impact of hypertension, diabetes, and obesity is particularly noted in African Americans. Exercise can reduce the risks for cardiovascular disease by promoting healthy weight, maintaining healthy blood pressure, and reducing the risk for development of diabetes. Global Rationale: It is appropriate to educate parents of school-aged children about the importance of screening for and treating strep in their children. This can help prevent rheumatic fever and the valvular problems that are associated with this infection. African Americans can benefit from blood pressure screening activities. Hypertension is often present without any symptoms so education about symptoms will not be particularly beneficial. Smokers have double the mortality rate from myocardial infarction than nonsmokers. The impact of hypertension, diabetes, and obesity is particularly noted in African Americans. Exercise can reduce the risks for cardiovascular disease by promoting healthy weight, maintaining healthy blood pressure, and reducing the risk for development of diabetes. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.8: Discuss the objectives in Healthy People 2020 as they relate to the cardiovascular system. Question 28 Type: MCMA

The client is 3 months pregnant. The nurse recently reviewed the objectives of Healthy People 2020 regarding pregnant women. Which of the following statements by the client indicates adequate education has occurred according to the objectives? Standard Text: Select all that apply. 1. “I never got my rubella vaccination so I’ve been staying away from my niece who has rubella.” 2. “I stopped taking Accutane for my acne before we started trying to get pregnant.” 3. “I have been so careful about taking my insulin now that I’m pregnant.” 4. “I have just one glass of wine each evening.” 5. “I had to change to a different medication to prevent my seizures before we got pregnant.” Correct Answer: 1,2,3,5 Rationale 1: “I never got my rubella vaccination so I’ve been staying away from my niece who has rubella.” Pregnant females who have not had or been immunized against rubella must avoid contraction of the virus during the first trimester of pregnancy. Rationale 2: “I stopped taking Accutane for my acne before we started trying to get pregnant.” The use of Accutane during pregnancy can increase the risk of having a child with congenital heart defects. Rationale 3: “I have been so careful about taking my insulin now that I’m pregnant.” Females with diabetes mellitus have an increased risk of having a child with a heart defect. Careful regulation of the diabetes before and in early pregnancy can reduce the risk. Rationale 4: “I just have one glass of wine each evening.” It is not appropriate to drink alcohol during pregnancy because it increases the risk of having a child with birth defects. Rationale 5: “I had to change to a different medication to prevent my seizures before we got pregnant.” Some anti-seizure medications can increase the risk of having a child with a heart defect. Global Rationale: Pregnant females who have not had or been immunized against rubella must avoid contraction of the virus during the first trimester of pregnancy. The use of Accutane during pregnancy can increase the risk of having a child with congenital heart defects. Females with diabetes mellitus have an increased risk of having a child with a heart defect. Careful regulation of the diabetes before and in early pregnancy can reduce the risk. It is not appropriate to drink alcohol during pregnancy because it increases the risk of having a child with birth defects. Some anti-seizure medications can increase the risk of having a child with a heart defect. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.8: Discuss the objectives in Healthy People 2020 as they relate to the cardiovascular system.

Question 29 Type: MCMA The Emergency Department nurse determines that the client may be having a myocardial infarction. Which of the following pieces of information indicate that the client is experiencing an acute cardiovascular problem? Standard Text: Select all that apply. 1. Blood pressure has dropped from normal and is 90/52. 2. Apical heart rate is 114 beats per minute. 3. Skin is flushed and warm. 4. Respiratory rate is 28 per minute. 5. The client is complaining of a headache. Correct Answer: 1,2,4 Rationale 1: Blood pressure has dropped from normal is 90/52. This client is hypotensive and this suggests that an acute cardiovascular problem may be occurring. Rationale 2: Apical heart rate is 114 beats per minute. The client is tachycardic and this is indicative of an acute cardiovascular problem. Rationale 3: Skin is flushed and warm. Warm, flushed skin is not necessarily associated with an acute cardiovascular problem. Cyanosis, blue or gray-tinged skin, and pallor are associated with an acute cardiovascular problem. Rationale 4: Respiratory rate is 28 per minute. This client is tachypneic and this is associated with an acute cardiovascular problem. Rationale 5: The client is complaining of a headache. A headache is not necessarily a symptom of an acute cardiovascular problem. Global Rationale: This client is hypotensive and this suggests that an acute cardiovascular problem may be occurring. The client is tachycardic and this is indicative of an acute cardiovascular problem. Warm, flushed skin is not necessarily associated with an acute cardiovascular problem. Cyanosis, blue or gray-tinged skin, and pallor are associated with an acute cardiovascular problem. This client is tachypneic and this is associated with an acute cardiovascular problem. A headache is not necessarily a symptom of an acute cardiovascular problem. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.9: Apply critical thinking in selected simulations related to physical assessment of the cardiovascular system.

Question 30 Type: MCSA The client has been admitted to the Coronary Care Unit with a myocardial infarction. Which of the following statements by the client indicate that adequate learning has occurred? 1. “I’m just sick to my stomach because I ate something that didn’t agree with me.” 2. “I think I must have given myself a little too much insulin this morning.” 3. “I’ve been breathing fast and my heart’s been racing because my heart’s not working right.” 4. “Just give me something for the nausea and I can go home.” Correct Answer: 3 Rationale 1: The client believes that the nausea is unrelated to an acute cardiovascular event such as a myocardial infarction. Rationale 2: The client believes that his symptoms are related to hypoglycemia and will require education about the seriousness of his heart condition. Rationale 3: The client is correct when he states that his heart is not working well and his respiratory rate and heart rate are up because of it. Rationale 4: The client will be unable to go home until after he is stabilized and medically fit to return home. Global Rationale: The client does not understand the importance of the symptoms that he is experiencing. The client believes that the nausea is unrelated to an acute cardiovascular event such as a myocardial infarction. The client believes that his symptoms are related to hypoglycemia and will require education about the seriousness of his heart condition. The client is correct when he states that his heart is not working well and his respiratory rate and heart rate are up because of it. The client will be unable to go home until after he is stabilized and medically fit to return home. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.9: Apply critical thinking in selected simulations related to physical assessment of the cardiovascular system.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 18 Question 1 Type: HOTSPOT The nurse is preparing to assess the client’s dorsalis pedis pulse. Draw an arrow to where this pulse can be palpated on the following figure.

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The dorsalis pedis pulses may be felt on the medial side of the dorsum of the foot. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.1: Identify the anatomy and physiology of the peripheral vascular and lymphatic systems. Question 2 Type: MCSA 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. “Your lymph nodes filter blood for your body.” 2. “They are responsible for the break down of old red blood cells.” 3. “They make lymphocytes for you.” 4. “Your lymph nodes help to remove infectious organisms.” Correct Answer: 4 Rationale 1: Lymph nodes actually filter lymph fluid before returning it to the client’s blood. Rationale 2: The liver is responsible for breaking down old red blood cells. Rationale 3: Lymphocytes are not made in lymph nodes. Lymph nodes filter lymph fluid before returning it the blood. Rationale 4: This statement is accurate. The lymph fluid is filtered in the lymph node to remove pathogens before returning it the bloodstream. Global Rationale: The lymph fluid is filtered in the lymph node to remove pathogens before returning it the bloodstream. The liver is responsible for breaking down old red blood cells. Lymphocytes are not made in lymph nodes. Lymph nodes filter lymph fluid before returning it the blood. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.1: Identify the anatomy and physiology of the peripheral vascular and lymphatic systems. Question 3 Type: MCMA

The nurse is performing a focused interview with a client who was recently diagnosed with varicose veins. Which of the following statements by the client are associated with risk factors for varicose veins? Standard Text: Select all that apply. 1. “My mother had big veins on her legs from the time I was little.” 2. “My father is of Japanese descent.” 3. “I’m a hair stylist.” 4. “I was pregnant once and have a son.” 5. “I know I weigh a lot more than I should.” Correct Answer: 1,3,5 Rationale 1: “My mother had big veins on her legs from the time I was little.” A client who has a family history of varicose veins has an increased risk for developing them. Rationale 2: “My father is of Japanese descent.” Risk factors for varicose veins include people who are of Irish or German descent. People of Japanese descent do not necessarily have an increased risk of developing varicose veins. Rationale 3: “I’m a hair stylist.” Hair stylists are more likely to be on their feet while they are working and this does result in an increase in their risk of developing varicose veins. Rationale 4: “I was pregnant once and have a son.” People who have been pregnant multiple times have an increased risk for developing varicose veins. Rationale 5: “I know I weigh a lot more than I should.” People who are obese have an increased risk for developing varicose veins. Global Rationale: A client who has a family history of varicose veins has an increased risk for developing them. Risk factors for varicose veins include people who are of Irish or German descent. People of Japanese descent do not necessarily have an increased risk of developing varicose veins. Hair stylists are more likely to be on their feet while they are working and this does result in an increase in their risk of developing varicose veins. People who have been pregnant multiple times have an increased risk for developing varicose veins. People who are obese have an increased risk for developing varicose veins. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.2: Develop questions that guide the focused interview. Question 4 Type: MCMA

While performing a focused interview with a healthy adult client, the nurse notes frequent position changes, wringing of hands, lack of eye contact, incomplete sentences, and rapid speech. The vital signs are BP 160/88, apical pulse 102 beats per minute, respiratory rate 26 per minute. Which of the following are appropriate responses by the nurse? Standard Text: Select all that apply. 1. “I’m going to take your temperature now.” 2. “Have you ever experienced chest pain?” 3. “Are you feeling any anxiety right now?” 4. “Are you experiencing any pain at this time?” 5. “Have you ever been diagnosed with hypothyroidism?” Correct Answer: 2,3,4 Rationale 1: “I’m going to take your temperature now.” It will be appropriate to assess the client’s temperature, but the nurse should first determine whether the client is in pain or is experiencing anxiety. Rationale 2: “Have you ever experienced chest pain?” The client’s actions may indicate that the client is experiencing pain. Pain can result in increased blood pressure, pulse, and respiratory rate. The nurse should determine if the client is experiencing pain and seek to treat the pain prior to continuing with the focused interview. Rationale 3: “Are you feeling any anxiety right now?” The client’s actions are consistent with anxiety. Anxiety stimulates the sympathetic nervous system, which can result in vasoconstriction, high blood pressure, increased heart rate, and respiratory rate. Rationale 4: “Are you experiencing any pain at this time?” The client may be experiencing chest pain. The nurse should determine whether the client is experiencing chest pain prior to continuing the focused interview. Rationale 5: “Have you ever been diagnosed with hypothyroidism?” The client’s vital signs and actions are more likely associated with hyperthyroidism. Global Rationale: It will be appropriate to assess the client’s temperature, but the nurse should first determine whether the client is in pain or is experiencing anxiety. The client’s actions may indicate that the client is experiencing pain. The client may be experiencing chest pain. The nurse should determine whether the client is experiencing chest pain prior to continuing the focused interview. Pain can result in increased blood pressure, pulse, and respiratory rate. The nurse should determine if the client is experiencing pain and seek to treat the pain prior to continuing with the focused interview. The client’s actions are also consistent with anxiety. Anxiety stimulates the sympathetic nervous system, which can result in vasoconstriction, high blood pressure, increased heart rate, and respiratory rate. The client’s vital signs and actions are more likely associated with hyperthyroidism. Cognitive Level: Applying

Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.2: Develop questions that guide the focused interview. Question 5 Type: MCMA The student nurse is performing an assessment of the client’s peripheral vascular system with the experienced nurse’s guidance. Which of the following actions by the student nurse indicate that the student nurse requires further education? Standard Text: Select all that apply. 1. The student nurse continues to assess the client while the client is in a flat, supine position. The client’s respiratory rate increases to 26 breaths per minute and the client becomes dusky around the mouth and lips. 2. The student nurse requests that the client remove all undergarments prior to putting the gown. 3. The client left her socks on and the student nurse assesses the client’s pedal pulses over the socks. 4. The client is wearing multiple rings and bracelets. The student nurse states that she may leave them on during the examination. 5. The student nurse takes a blood pressure cuff, Doppler, and stethoscope into the client’s room for this assessment. Correct Answer: 1,2,3,4 Rationale 1: The student nurse continues to assess the client while the client is in a flat, supine position. The client’s respiratory rate increases to 26 breaths per minute and the client becomes dusky around the mouth and lips. The student nurse should pay careful attention to how well the client tolerates certain positions during the assessment. At this point, the student nurse should sit the client up to allow the client to breathe better. Rationale 2: The student nurse requests that the client remove all undergarments prior to putting the gown . The client can leave on undergarments for this assessment. Rationale 3: The client left her socks on and the student nurse assesses the client’s pedal pulses over the socks. Socks should be removed prior to assessing the client’s feet. Pulses, skin temperature, skin color, quality of sensation, and capillary refill should be assessed and this would be extremely difficult to assess while the client’s socks are on her feet. Rationale 4: The client is wearing multiple rings and bracelets. The student nurse states that she may leave them on during the examination. The client should take off her jewelry. Pulses may difficult to palpate around bracelets. Rationale 5: The student nurse takes a blood pressure cuff, Doppler, and stethoscope into the client’s room for this assessment. These pieces of equipment are required to perform this assessment.

Global Rationale: The student nurse must pay attention to how well the client tolerates the various positions during the assessment. The client needs to remove only socks and shoes prior to putting on the gown. The socks must be removed to accurately assess the peripheral vascular system. The client should take off her jewelry prior to the assessment. It is appropriate to bring these pieces of equipment for the assessment. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.3: Explain client preparation for assessment of the peripheral vascular system. Question 6 Type: MCSA The nursing student is learning about the appropriate method to use when assessing a client’s blood pressure. The student nurse asks the nursing instructor why it is necessary to palpate the systolic pressure prior to the procedure. Which of the following is the nursing instructor’s best response? 1. “You can document this value if you cannot hear the blood pressure well.” 2. “This needs to be done only when the client is developing clinical manifestations associated with shock.” 3. “You are more likely to get an accurate reading when you do it this way.” 4. “It is the best way to determine an arterial obstruction.” Correct Answer: 3 Rationale 1: It is not appropriate to merely document the palpable systolic pressure. Efforts should be made to document the client’s blood pressure. Rationale 2: When a client is developing clinical manifestations associated with shock, his blood pressure is more likely to be lower than normal. The nurse should palpate the systolic pressure for all clients regardless of their diagnoses. Rationale 3: Assessing the palpable systolic pressure helps to avoid inaccuracy in blood pressure assessment that can occur with an ausculatory gap, or space in which beats are not heard, during this assessment. Rationale 4: This can be assessed by measuring the difference between the blood pressures in the arms. A difference of 10 mm Hg or more between the arms may indicate an obstruction of arterial flow to one arm. Global Rationale: Assessing the palpable systolic pressure helps to avoid inaccuracy in blood pressure assessment that can occur with an ausculatory gap, or space in which beats are not heard, during this assessment. It is not appropriate to merely document the palpable systolic pressure. Efforts should be made to document the client’s blood pressure. When a client is developing clinical manifestations associated with shock, his blood pressure is more likely to be lower than normal. The nurse should palpate the systolic pressure for all clients regardless of their diagnoses. Arterial obstruction can be assessed by measuring the difference between the blood

pressures in the arms. A difference of 10 mm Hg or more between the arms may indicate an obstruction of arterial flow to one arm. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.4: Describe techniques required for assessment of the peripheral vascular system. Question 7 Type: MCMA The student nurse is preparing to perform an assessment of the client’s peripheral vascular system. The experienced nurse asks the student nurse questions to ensure the student nurse has prepared adequately. Which of the following statements by the student nurse indicate that further education is required? Standard Text: Select all that apply. 1. “I need to take a blood pressure only in the client’s right arm.” 2. “The best way to assess the carotid pulses is palpate one side and then the other.” 3. “It will be easier to assess the client’s carotid pulses if the client is obese.” 4. I should inspect the arms to ensure that they are close to the same size.” 5. “I should look at the extremities to ensure that hair distribution is normal and symmetrical. The skin should be clean and free of any lesions.” Correct Answer: 1,3 Rationale 1: “I need to take a blood pressure only in the client’s right arm.” A thorough peripheral vascular assessment includes blood pressure measurements taken in both arms and both legs. Rationale 2: “The best way to assess the carotid pulses is palpate one side and then the other.” The carotid pulses should not be palpated at the same time because it may cause the client to faint or pass out due to lack of blood flow to the brain. Rationale 3: “It will be easier to assess the client’s carotid pulses if the client is obese.” It is much easier to assess the client’s carotid pulses when the client has a long, thin neck. Rationale 4: “I should inspect the arms to ensure that they are close to the same size.” The arms should be compared to each other to ensure that there is not a lymphatic problem that has developed that would result in edema. Rationale 5: “I should look at the extremities to ensure that hair distribution is normal and symmetrical. The skin should be clean and free of any lesions.” The skin on the extremities should be clean, dry, and intact. The client’s pattern of hair distribution should be evaluated to determine if there is adequate arterial circulation.

Global Rationale: The student nurse should take the client’s blood pressure in both arms and both legs. It will be more difficult to assess the client’s carotid pulses if the client is obese or has a short neck. The best way to palpate the client’s carotid pulses is separately and not simultaneously. The student nurse should ensure that both arms are equal in size. The student nurse should thoroughly assess the client’s extremities. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.4: Describe techniques required for assessment of the peripheral vascular system. Question 8 Type: MCMA The nurse is thoroughly assessing the client for any peripheral vascular problems. The client requested the nurse to state exactly what the nurse was looking for during the assessment. Which of the following statements by the nurse are unexpected? Standard Text: Select all that apply. 1. “I am feeling your feet to see how warm they are.” 2. I am looking for hair on your toes.” 3. I am going to perform the Trendelenburg’s test to see how well the radial and ulnar arteries are supplying blood to your hand.” 4. I am going to test your ability to feel sensations by giving you an injection.” 5. “I am going to perform the Allen’s test to see if you have any varicose veins.” Correct Answer: 3,4,5 Rationale 1: “I am feeling your feet to see how warm they are.” Warmth felt at the distal portions of the extremities indicate that the client is receiving an adequate amount of arterial blood flow to those areas. Rationale 2: “I am looking for hair on your toes.” Hair growth on the client’s toes indicates that the client is receiving an adequate amount of arterial blood flow to the toes. This is especially helpful when the client routinely shaves the hair from the legs. Rationale 3: “I am going to perform the Trendelenburg’s test to see how well the radial and ulnar arteries are supplying blood to your hand.” The Trendelenburg’s test is used to determine varicose veins. Rationale 4: “I am going to test your ability to feel sensations by giving you an injection.” The nurse should assess the client’s ability to feel sensations by using the sharp and dull ends of a safety pin. An adequate ability to feel sensations indicates adequate arterial blood flow.

Rationale 5: “I am going to perform the Allen’s test to see if you have any varicose veins.” The Allen’s test is used to determine if the client has problems with arterial blood flow from the radial and ulnar arteries to the client’s hand. Global Rationale: It is important for the nurse to assess the client’s peripheral extremities to determine temperature. Hair growth on toes indicates adequate arterial blood flow. The Allen’s test is used to determine patency of the radial and ulnar arteries. The nurse should use a safety pin to assess the client’s ability to feel dull and sharp sensations. The Trendelenburg’s test can be used to determine if the client has varicose veins in the legs. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.4: Describe techniques required for assessment of the peripheral vascular system. Question 9 Type: MCSA The nursing student is learning about blood pressure assessment and asks the instructor about blood pressure values. Which of the following responses is an accurate response? 1. “A normal blood pressure always depends on the client’s previous values.” 2. “A normal blood pressure is below 140/90.” 3. “A client with prehypertension has a blood pressure that is greater than 140/90.” 4. “A client with stage II hypertension has a blood pressure that is greater than 160/100.” Correct Answer: 4 Rationale 1: There are some specific guidelines set forth by the National Institutes of Health that can be used to classify a client’s blood pressure as “normal,” “prehypertension,” “stage I hypertension,” and “stage II hypertension.” Rationale 2: A normal blood pressure is actually less than 120 (systolic) and less than 80 (diastolic). Rationale 3: A client with prehypertension will have a blood pressure of 120–139 (systolic) and 80–89 (diastolic). Rationale 4: This is an accurate response. The client with stage II hypertension will have a blood pressure greater than or equal to 160 (systolic) and greater than or equal to 100 (diastolic). Global Rationale: There are some specific guidelines set forth by the National Institutes of Health that can be used to classify a client’s blood pressure as “normal,” “prehypertension,” “stage I hypertension,” and “stage II hypertension.” The client with stage II hypertension will have a blood pressure greater than or equal to 160 (systolic) and greater than or equal to 100 (diastolic). A normal blood pressure is actually less than 120 (systolic)

and less than 80 (diastolic). A client with prehypertension will have a blood pressure of 120–139 (systolic) and 80–89 (diastolic). Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 10 Type: MCSA The nurse is taking the blood pressure of a client. The nurse obtains the blood pressure in both of the client’s arms. The nurse determines that there is a difference of 15 mm Hg in the systolic readings between the arms and repeats the assessment with the same results. The nurse suspects which of the following may have occurred in this situation? 1. Inaccurate technique 2. Anxiety 3. Unilateral arterial obstruction 4. Shock Correct Answer: 3 Rationale 1: After repeating the procedure and determining the results were the same, the nurse would not necessarily assume that the technique was faulty. Rationale 2: Client anxiety may result in a higher blood pressure reading. It would not result in a difference between blood pressures assessed in each arm. Rationale 3: A difference of readings 10 mm Hg or more between arms may indicate an obstruction of arterial blood flow to one arm and is considered an abnormal finding. Rationale 4: If the client is developing clinical manifestations associated with shock, the nurse would most likely determine that the client’s blood pressure is lower than normal. Shock would not result in a difference between blood pressures assessed in each arm. Global Rationale: A difference of readings 10 mm Hg or more between arms may indicate an obstruction of arterial blood flow to one arm and is considered an abnormal finding. After repeating the procedure and determining the results were the same, the nurse would not necessarily assume that the technique was faulty. Client anxiety may result in a higher blood pressure reading. It would not result in a difference between blood pressures assessed in each arm. If the client is developing clinical manifestations associated with shock, the nurse would most likely determine that the client’s blood pressure is lower than normal. Shock would not result in a difference between blood pressures assessed in each arm.

Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 11 Type: MCSA The nurse examines the peripheral vascular system of a client diagnosed with chronic bronchitis 22 years ago. The nurse examines the client’s hand. Which of the following statements by the client is consistent with the client’s diagnosis? 1. “My fingers look so pointy and narrow at the ends.” 2. “My fingernails are as hard as a rock.” 3. “My nails always look a little bluish.” 4. “My nails have a lot of strange ridges in them.” Correct Answer: 3 Rationale 1: Many times, clients with a long-term history of chronic hypoxia such as chronic bronchitis, will exhibit clubbing of their fingers. The fingertips will look large at the ends. Rationale 2: Clients with lung problems resulting in chronic hypoxia will more likely to complain that their nails are soft and spongy. Rationale 3: This is a likely statement from someone who has a long history of disorder resulting in chronic hypoxia. The nails may look blue or gray due to oxygen deprivation. Rationale 4: his is more likely the result of another disorder such as a nutritional deficiency. Global Rationale: The statement regarding blueness is a likely statement from someone who has a long history of disorder resulting in chronic hypoxia. The nails may look blue or gray due to oxygen deprivation. Many times, clients with a long-term history of chronic hypoxia such as chronic bronchitis, will exhibit clubbing of their fingers. The fingertips will look large at the ends, not pointy and narrow. Clients with lung problems resulting in chronic hypoxia will more likely to complain that their nails are soft and spongy. Ridges in the nails are more likely the result of another disorder such as a nutritional deficiency. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 12 Type: MCSA 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. Skin turgor 2. Calf measurements 3. Homan’s sign 4. Peripheral pulses Correct Answer: 4 Rationale 1: The nurse can use information about the client’s skin turgor to help assess the client’s fluid balance. Rationale 2: Calf measurements can be compared to determine if the client is developing edema. This information will be more helpful to use with a client who has venous insufficiency. Rationale 3: Homan’s sign can be used to help determine if the client has developed a deep vein thrombosis. Rationale 4: Peripheral pulses should be assessed to determine if the client has arterial insufficiency. This is the most useful assessment at this time. Global Rationale: Peripheral pulses should be assessed to determine if the client has arterial insufficiency. This is the most useful assessment at this time. The nurse can use information about the client’s skin turgor to help assess the client’s fluid balance. Calf measurements can be compared to determine if the client is developing edema. This information will be more helpful to use with a client who has venous insufficiency. Homan’s sign can be used to help determine if the client has developed a deep vein thrombosis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 13 Type: MCSA

The nurse is assessing a client admitted to the hospital for congestive heart failure and notes 1+ pitting edema of the left arm, as well as bilateral 1+ pitting edema in the client’s ankles. The client’s history indicates that the client has had a myocardial infarction and a left mastectomy. The nurse would suspect which of the following causes for the edema in the left arm? 1. Impaired lymphatic drainage 2. Noncompliance with medication regimen 3. Right-sided heart failure 4. Excessive intake of sodium Correct Answer: 1 Rationale 1: This client most likely has developed lymphedema due to the removal of lymph nodes during the client’s mastectomy. This type of surgery can inhibit the body’s ability to drain lymph from the client’s affected arm. Rationale 2: Noncompliance with medication may result in edema that affects the client’s bilateral peripheral extremities. Unilateral edema indicates that there is a problem with the way the lymph is able to drain from the client’s extremity. Rationale 3: Right-sided heart failure often results in bilateral pitting edema. Unilateral pitting edema indicates that the lymph is not draining well from the client’s arm. Rationale 4: Increased sodium intake can result in edema. However, this would most likely result in bilateral peripheral edema. Global Rationale: This client most likely has developed lymphedema due to the removal of lymph nodes during the client’s mastectomy. This type of surgery can inhibit the body’s ability to drain lymph from the client’s affected arm. Noncompliance with medication may result in edema that affects the client’s bilateral peripheral extremities. Unilateral edema indicates that there is a problem with the way the lymph is able to drain from the client’s extremity. Right-sided heart failure often results in bilateral pitting edema. Unilateral pitting edema indicates that the lymph is not draining well from the client’s arm. Increased sodium intake can result in edema. However, this would most likely result in bilateral peripheral edema. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 14 Type: MCSA

The nurse is completing an assessment on a client following a cardiac catheterization procedure. During the initial assessment, the nurse easily palpates the client’s right dorsalis pedis and posterior tibial pulses. The pulses on the client’s left leg are strong and easily palpable. During the next assessment, the nurse is unable to palpate or find these pulses on the right side with a Doppler. Which of the following would be the most appropriate action for the nurse at this time? 1. Notify the healthcare provider immediately. 2. Assess for the client’s right popliteal pulse. 3. Take the client’s blood pressure. 4. Place the client in Trendelenburg position. Correct Answer: 2 Rationale 1: The nurse should attempt to palpate the client’s popliteal pulse. The healthcare provider should be notified, but the nurse should be prepared to provide information about the client’s popliteal pulse during their conversation. Rationale 2: This is the appropriate action at this time. This will help the nurse determine how much of this extremity is still receiving oxygenated blood. Rationale 3: After the nurse assesses the client’s popliteal pulses, it may be appropriate to check the client’s vital signs prior to notifying the healthcare provider. Rationale 4: Trendelenberg can be used to treat a client in shock. The information about the client does not indicate that the client has developed clinical manifestations associated with shock. Global Rationale: The nurse should attempt to palpate the client’s popliteal pulse. This will help the nurse determine how much of this extremity is still receiving oxygenated blood. After the nurse assesses the client’s popliteal pulses, it may be appropriate to check the client’s vital signs prior to notifying the healthcare provider. The healthcare provider should be notified, but the nurse should be prepared to provide information about the client’s condition during their conversation. Trendelenberg can be used to treat a client in shock. The information about the client does not indicate that the client has developed clinical manifestations associated with shock. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 15 Type: MCMA While assessing a client with a laceration on the client’s left third finger, the nurse notes the presence of inflammation and swelling of the finger. The nurse might expect to find which of the following?

Standard Text: Select all that apply. 1. 1cm, nontender, soft, left brachial node 2. cm, tender, firm, left superior superficial inguinal node 3. 2 cm, tender, firm, left epitrochlear node 4. cm, nontender, firm, left ulnar node 5. cm, tender, firm, left axillary lymph node Correct Answer: 3,5 Rationale 1: 1cm, nontender, soft, left brachial node. A 1 cm lymph node is not necessarily enlarged. Tenderness usually indicates the presence of infection. Firmness can indicate infection. Rationale 2: 2 cm, tender, firm, left superior superficial inguinal node. An infected wound on the client’s left third finger may result in a tender enlarged firm epitrochlear, brachial, and axillary lymph nodes. The left superior superficial inguinal node drains lymph from the client’s left leg. Rationale 3: 2 cm, tender, firm, left superior superficial inguinal node. Normally, the epitrochlear nodes are not palpable. A tender, firm and enlarged node such as this one may indicate the client has an infection. The epitrochlear node drains the forearm and third, fourth, and fifth fingers. A lymph node indicative of infection will be greater than 1 cm, tender, and mobile. Rationale 4: 2 cm, nontender, firm, left ulnar node. The epitrochlear node drains lymph from the ulnar area. Lymph nodes in the arm are the following: subclavicular, central axillary, brachial, and epitrochlear. Rationale 5: 2 cm, tender, firm, left axillary lymph node. The client with an infected wound on the left finger may have a tender enlarged lymph node in the axilla that can be found with light palpation. Global Rationale: Normally, the epitrochlear nodes are not palpable. A tender, firm and enlarged node such as this one may indicate the client has an infection. The epitrochlear node drains the forearm and third, fourth, and fifth fingers. The client with an infected wound on the left finger may have a tender enlarged lymph node in the axilla that can be found with light palpation. A lymph node indicative of infection will be greater than 1 cm, tender, and mobile. The left superior superficial inguinal node drains lymph from the client’s left leg. The epitrochlear node, not the ulnar node, drains lymph from the ulnar area. Lymph nodes in the arm are the following: subclavicular, central axillary, brachial, and epitrochlear. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 16 Type: MCMA

The nurse is performing the assessment of an elderly client recently diagnosed with arterial insufficiency due to atherosclerosis. Which of the following findings are consistent with this condition? Standard Text: Select all that apply. 1. Bilateral pitting edema 3+ in ankles and feet 2. Carotid bruit present 3. Blood pressure 180/94 4. Peripheral pulses 1+/4+ in dorsalis pedis bilaterally 5. A pea-sized ulcer noted on the client’s right great toe, no drainage, well-defined edges Correct Answer: 2,3,4,5 Rationale 1: Bilateral pitting edema 3+ in ankles and feet. Bilateral pitting edema is most often attributed to right-sided heart failure. Rationale 2: arotid bruit present. A narrowing of the carotid artery, as occurs with atherosclerosis, will result in turbulent blood flow. This causes the swishing sound known as a bruit. Rationale 3: Blood pressure 180/94. Clients with atherosclerosis and arterial insufficiency may have hypertension. Rationale 4: Peripheral pulses 1+/4+ in dorsalis pedis bilaterally. Atherosclerosis and arterial insufficiency may result in decreased peripheral pulses. Rationale 5: A pea-sized ulcer noted on the client’s right great toe, no drainage, well-defined edges. The client with arterial insufficiency may develop ulcers such as this one. Global Rationale: A narrowing of the carotid artery, as occurs with atherosclerosis, will result in turbulent blood flow. This causes the swishing sound known as a bruit. Clients with atherosclerosis and arterial insufficiency may have hypertension. Atherosclerosis and arterial insufficiency may result in decreased peripheral pulses. The client with arterial insufficiency may develop ulcers such as this one. Bilateral pitting edema is most often attributed to right-sided heart failure. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system Question 17 Type: MCSA

The nurse is caring for a client who may have an arterial obstruction in her right ulnar artery. Which of the following tests may be used to help determine the patency of this artery? 1. Trendelenburg test 2. Manual compression test 3. Homan’s sign 4. Allen’s test Correct Answer: 4 Rationale 1: This test can be used to evaluate valve competence in the presence of varicosities. Rationale 2: If varicose veins are present, the nurse can determine the length of the varicose vein and the competency of its valves with the manual compression test. Rationale 3: The test to elicit a Homan’s sign can be used to help determine if the client has a thrombosis. Rationale 4: The Allen’s test is used to evaluate the patency of both the radial and ulnar arteries. Global Rationale: The Allen’s test is used to evaluate the patency of both the radial and ulnar arteries. The Trendelenberg test can be used to evaluate valve competence in the presence of varicosities. If varicose veins are present, the nurse can determine the length of the varicose vein and the competency of its valves with the manual compression test. The test to elicit a Homan’s sign can be used to help determine if the client has a thrombosis. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 18 Type: MCMA The nurse is assessing a client who may have arterial insufficiency in the left lower leg. Which of the following are consistent with this diagnosis? Standard Text: Select all that apply. 1. Left dorsalis pedis pulse +1, right dorsalis pedis pulse +3 2. Skin is cool, tight, and shiny 3. When left leg is dependent, erythema is present

4. When left leg is elevated, pallor is present 5. Client complains of increased pain during rest periods Correct Answer: 1,2,3,4 Rationale 1: Left dorsalis pedis pulse +1, right dorsalis pedis pulse +3. The client with arterial insufficiency may have diminished pulses. The pulse in the left foot is difficult to palpate, while the pulse in the right foot is strong and easy to palpate. Rationale 2: Skin is cool, tight, and shiny. This finding is consistent with arterial insufficiency. The affected limb will feel cool. The skin may look “tight” and appear shiny. These findings indicate that the limb is not receiving an adequate arterial supply of oxygenated blood. Rationale 3: When left leg is dependent, erythema is present. This finding is consistent with arterial insufficiency. When in a dependent position, the affected limbs will become reddened. Rationale 4: When left leg is elevated, pallor is present. This finding is consistent with arterial insufficiency. When elevated, affected limbs will become pale. Rationale 5: Client complains of increased pain during rest periods. The client with arterial insufficiency is more likely to complain of pain during exercise of the leg. The pain decreases or is absent with rest. Global Rationale: The client with arterial insufficiency may have diminished pulses. The pulse in the left foot is difficult to palpate, but the pulse in the right foot is strong and easy to palpate. The affected limb will feel cool. The skin may look “tight” and appear shiny. These findings indicate that the limb is not receiving an adequate arterial supply of oxygenated blood. When in a dependent position, the affected limbs will become reddened. When elevated, affected limbs will become pale. The client with arterial insufficiency is more likely to complain of pain during exercise of the leg. The pain decreases or is absent with rest. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 19 Type: MCMA The client was recently diagnosed with venous insufficiency. Which of the following statements by the client are consistent with this diagnosis? Standard Text: Select all that apply. 1. “My legs are so cold that they feel like ice.” 2. “My ankles and feet are always swollen.”

3. “The skin on my leg looks so pale.” 4. “When I walk around a lot, my legs just ache.” 5. “I have an ulcer on my inner leg above my ankle that just bleeds and bleeds.” Correct Answer: 2,5 Rationale 1: “My legs are so cold that they feel like ice.” Clients with arterial insufficiency may complain that their legs feel cool or cold. The nurse is more likely to determine that the legs of clients with venous insufficiency have temperatures that are within normal limits. Rationale 2: “My ankles and feet are always swollen.” Edema in the lower extremities is associated with venous insufficiency. Rationale 3: “The skin on my leg looks so pale.” Pale skin on the lower extremities is associated with arterial insufficiency. Venous insufficiency results in darkened skin on the lower extremities. Rationale 4: “When I walk around a lot, my legs just ache.” This statement is consistent with a client who has been diagnosed with arterial insufficiency. The type of discomfort associated with venous insufficiency is aggravated by prolonged standing or sitting and is relieved by several hours of rest. Rationale 5: I have an ulcer on my inner leg above my ankle that just bleeds and bleeds.” This type of ulcer is consistent with a diagnosis of venous insufficiency. These ulcers are more likely to bleed and can be found in this area of the lower extremity. Arterial insufficiency ulcers are often described as dry, pale, with defined edges. Global Rationale: Edema in the lower extremities is associated with venous insufficiency. The ulcers consistent with a diagnosis of venous insufficiency are likely to bleed and can be found in this area of the lower extremity. Arterial insufficiency ulcers are often described as dry, pale, with defined edges. Clients with arterial insufficiency may complain that their legs feel cool or cold. The nurse is more likely to determine that the legs of clients with venous insufficiency have temperatures that are within normal limits. Pale skin on the lower extremities is associated with arterial insufficiency. Venous insufficiency results in darkened skin on the lower extremities. Pain with walking is consistent with a client who has been diagnosed with arterial insufficiency. The type of discomfort associated with venous insufficiency is aggravated by prolonged standing or sitting and is relieved by several hours of rest. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 20 Type: MCSA

The client is visiting the healthcare provider’s office with complaints of discoloration of her hands. The client states, “My fingertips turn whitish and then later they get really red.” The nurse is not surprised to learn from the healthcare provider that the client has which of the following disorders? 1. Lymphedema 2. Raynaud’s disease 3. Thrombosis 4. Venous insufficiency Correct Answer: 2 Rationale 1: Lymphedema is often described as edema that occurs in an affected extremity that is not draining lymph properly. Rationale 2: The findings described are consistent with Raynaud’s disease, in which the arterioles in the fingers develop spasms, causing intermittent skin pallor or cyanosis, then redness. This condition is most commonly seen in young females. Rationale 3: These findings are not consistent with a venous clot in the client’s arm. Clients with clots may have no symptoms at all or may experience pain. Rationale 4: Venous insufficiency results in discomfort that is aggravated by prolonged standing or sitting and is relieved by rest. The client’s complaints are not consistent with venous insufficiency. Global Rationale: The findings described are consistent with Raynaud’s disease, in which the arterioles in the fingers develop spasms, causing intermittent skin pallor or cyanosis, then redness. This condition is most commonly seen in young females. Lymphedema is often described as edema that occurs in an affected extremity that is not draining lymph properly. Clients with clots may have no symptoms at all or may experience pain. Venous insufficiency results in discomfort that is aggravated by prolonged standing or sitting and is relieved by rest. The client’s complaints are not consistent with venous insufficiency. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 21 Type: MCSA 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. “Does the other arm swell also?” 3. “Tell me about your past surgical procedures.” 4. “Do you ever feel self-conscious about your arm?” Correct Answer: 3 Rationale 1: This client most likely has lymphedema. If salt intake was excessive, the nurse would also determine swelling in other extremities. Unilateral swelling indicates that there may be a problem with lymph drainage from the extremity. Rationale 2: This is a good question but the nurse can see at this time that there is unilateral swelling. This is not the most important question to ask at this time. Rationale 3: This is the most important thing for the nurse to determine. This information will help the nurse determine if the client has lymphedema due to a surgical procedure. Damage to or removal of lymph nodes can impact the ability of the lymph system to drain the arm adequately. Rationale 4: This is important for the nurse to determine. However, this is not the most important question to ask at this time. The nurse should seek to determine how the lymphedema developed. Global Rationale: This client most likely has lymphedema. Damage to or removal of lymph nodes can impact the ability of the lymph system to drain the arm adequately, so information about previous surgical procedures is the priority question. This information will help the nurse determine if the client has lymphedema due to a surgical procedure. If salt intake was excessive, the nurse would also find swelling in other extremities. Unilateral swelling indicates that there may be a problem with lymph drainage from the extremity. The client’s feelings of being selfconscious are important for the nurse to consider, but are not the most important at this time. The nurse should seek to determine how the lymphedema developed. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 22 Type: MCSA 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. Venous insufficiency 4. Phlebitis Correct Answer: 1 Rationale 1: This is consistent with valve incompetence that is associated with the development of varicose veins in the lower extremities. Rationale 2: The Trendelenberg test does not test for arterial insufficiency. The findings during the Trendelenberg test on this client demonstrate some issues with valve incompetence. Rationale 3: The findings during this client’s Trendelenberg test are consistent with valve incompetence, not venous insufficiency. The client with venous insufficiency will exhibit edema and a brownish discoloration in the lower extremities. Rationale 4: Phlebitis is an inflammation of the vein. The Trendelenberg test is not used to determine if the client has phlebitis. The client with phlebitis will complain of tenderness along the affected area of the vein. Global Rationale: This finding is consistent with valve incompetence that is associated with the development of varicose veins in the lower extremities. The Trendelenberg test does not test for arterial insufficiency. The findings are not consistent with venous insufficiency. The client with venous insufficiency will exhibit edema and a brownish discoloration in the lower extremities. Phlebitis is an inflammation of the vein. The Trendelenberg test is not used to determine if the client has phlebitis. The client with phlebitis will complain of tenderness along the affected area of the vein. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 23 Type: MCSA A client’s blood pressure is 138/86 mm Hg. The nurse classifies this client’s blood pressure as which of the following categories? 1. Normal 2. Prehypertension 3. Stage I hypertension 4. Stage II hypertension Correct Answer: 2

Rationale 1: Normal blood pressures are less than 120 (systolic) and less than 80 (diastolic). Rationale 2: This blood pressure is classified as prehypertension because it is between 130 and 139 (systolic) and 80 and 89 (diastolic). Rationale 3: Blood pressures falling into this category are those between 140 and 159 (systolic) or those between 90 and 99 (diastolic). Rationale 4: Blood pressures falling into this category are those greater than or equal to 160 (systolic) or greater than 100 (diastolic). Global Rationale: This blood pressure is classified as prehypertension because it is between 130 and 139 (systolic) and 80 and 89 (diastolic). Normal blood pressures are less than 120 (systolic) and less than 80 (diastolic). Blood pressures falling into the Stage I hypertension category are those between 140–159 (systolic) or those between 90 and 99 (diastolic). Blood pressures falling into the stage II hypertension category are those greater than or equal to 160 (systolic) or greater than 100 (diastolic). Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system. Question 24 Type: MCSA The nurse is performing an assessment on a healthy 5 year old and palpates two enlarged lymph nodes on the child’s neck. The lymph nodes are soft, mobile, nontender, and each is less than 1 cm in diameter. The nurse would choose which of the following actions in this situation? 1. Assess for an infected wound. 2. Document this as a normal finding. 3. Notify the healthcare provider. 4. Obtain an order for a throat culture. Correct Answer: 2 Rationale 1: It is a normal finding to determine that a child has several enlarged lymph nodes such as these. When lymph nodes are significantly enlarged, the nurse should assess the child for an infection. Rationale 2: This is appropriate since these enlarged lymph nodes are small, nontender, and mobile. Rationale 3: t is not necessary for the nurse to notify the healthcare provider at this time.

Rationale 4: This would be an appropriate nursing action if the child had significantly enlarged lymph nodes and evidence that an infection was present in the child’s pharynx. Global Rationale: It is a normal finding to determine that a child has several enlarged lymph nodes such as these. When lymph nodes are significantly enlarged, the nurse should assess the child for an infection. Documenting this as a normal finding is appropriate since these enlarged lymph nodes are small, nontender, and mobile. It is not necessary for the nurse to notify the healthcare provider at this time. Obtaining an order for a throat culture would be an appropriate nursing action if the child had significantly enlarged lymph nodes and evidence that an infection was present in the child’s pharynx. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the peripheral vascular system. Question 25 Type: MCSA The nurse is performing a peripheral vascular assessment of a female client who is 7 months pregnant. The nurse notes mild peripheral edema, all other findings were normal. Which of the following actions by the nurse would be appropriate? 1. Notify the healthcare provider immediately regarding this abnormal finding. 2. Obtain an order from the healthcare provider for a diuretic to reduce the client’s edema. 3. Document the findings as expected due to the client’s pregnancy. 4. Educate the client regarding ways to reduce the risk about peripheral vascular ulcer development. Correct Answer: 3 Rationale 1: Mild peripheral edema is an expected finding when a pregnant client is in her third trimester. The client’s healthcare provider does not need to be immediately notified. Rationale 2: The client does not need a diuretic to reduce the mild peripheral edema. This is a normal finding at this stage of the client’s pregnancy. Rationale 3: Pressure from the uterus on the lower extremities can obstruct venous return and can cause edema, varicosities of the leg, and hemorrhoids. Edema is an expected finding because the client is in her third trimester. Rationale 4: Peripheral edema is a normal finding at this stage of the client’s pregnancy. This client is not necessarily at a greater risk for developing a peripheral vascular ulcer. Global Rationale: Mild peripheral edema is an expected finding when a pregnant client is in her third trimester. Pressure from the uterus on the lower extremities can obstruct venous return and can cause edema, varicosities of

the leg, and hemorrhoids. The client’s healthcare provider does not need to be immediately notified. The client does not need a diuretic to reduce the mild peripheral edema. This client is not necessarily at a greater risk for developing a peripheral vascular ulcer. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the peripheral vascular system. Question 26 Type: MCSA A[1][2] 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. “We can have the healthcare provider write you a prescription today.” 2. “You will also have to take blood thinners.” 3. “I need to perform a Homan’s test on you.” 4. “Taking oral contraceptives increases your risk of developing clots.” Correct Answer: 4 Rationale 1: This client has a history of deep vein thrombosis. Her history and taking oral contraceptive use increases her risk for developing another thrombosis. Rationale 2: It would be better for this client to avoid using oral contraceptives and use another method of birth control. “Blood thinners’’ have significant side effects. Rationale 3: At this time, the client has not been taking the oral contraceptives. There is no information to indicate the client currently has a deep vein thrombosis. Rationale 4: This is an accurate response and the nurse’s best response. Global Rationale: This client has a history of deep vein thrombosis. Her history and oral contraceptive use increases her risk for developing another thrombosis. It would be better for this client to avoid using oral contraceptives and use another method of birth control. “Blood thinners’’ have significant side effects. There is no information to indicate the client currently has a deep vein thrombosis so Homan’s test is not appropriate. Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.7: Discuss the objectives in Healthy People 2020 as they relate to issues of the peripheral vascular system. Question 27 Type: MCSA The nurse is conducting a wellness presentation for a group of factory employees and notes a large number of African Americans present. Based on information included in Healthy People 2020, the nurse would choose which of the following topics as a priority for this setting? 1. Cancer risk reduction 2. Bone density assessments 3. Smoking cessation 4. Blood pressure screening Correct Answer: 4 Rationale 1: African Americans do not typically have an increased risk of all types of cancers. Rationale 2: African Americans do not have an increased risk of developing osteoporosis. Rationale 3: Smoking cessation techniques are important to discuss, but hypertension is something that affects many African Americans. Rationale 4: This is an appropriate activity because African Americans have an increased risk of developing hypertension. Global Rationale: African Americans have an increased risk of developing hypertension. African Americans do not typically have an increased risk of all types of cancers or of developing osteoporosis. Smoking cessation techniques are important to discuss, but hypertension is something that affects many African Americans. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.7: Discuss the objectives in Healthy People 2020 as they relate to issues of the peripheral vascular system. Question 28 Type: MCMA The nurse is caring for a male client who is complaining of dizziness when standing. The client has been compliant with his antihypertensive medication. Which of the following statements by the client are commonly associated with antihypertensive medication use?

Standard Text: Select all that apply. 1. “Sometimes, I just feel so sick to my stomach.” 2. “I have frequent headaches.” 3. “My sex life hasn’t been so good since I started taking this medication.” 4. “I have a rash all over my back.” 5. “I don’t seem to pee as much as I did before I started this medication.” Correct Answer: 1,2,3 Rationale 1: “Sometimes, I just feel so sick to my stomach.” Nausea is associated with antihypertensive medication use. Rationale 2: “I have frequent headaches.” Headaches can be associated with antihypertensive medication use. Rationale 3: “My sex life hasn’t been so good since I started taking this medication.” Clients who use antihypertensive medications to control their blood pressure might experience a decrease in their sex drive. Impotence can occur in male clients. Rationale 4: “I have a rash all over my back.” This sign is not necessarily commonly associated with antihypertensive medication use. Rationale 5: “I don’t seem to pee as much as I did before I started this medication.” This is an atypical complaint. Clients who take diuretics to control their blood pressure may find that they are voiding more than usual. Global Rationale: Nausea and headaches are associated with antihypertensive medication use. Clients who use antihypertensive medications to control their blood pressure might experience a decrease in their sex drive. Impotence can occur in male clients. Rashes are not necessarily commonly associated with antihypertensive medication use. Clients who take diuretics to control their blood pressure may find that they are voiding more than usual. This is not found with antihypertensive medications other than diuretics. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.7: Discuss the objectives in Healthy People 2020 as they relate to issues of the peripheral vascular system. Question 29 Type: MCMA The client is a 38-year-old female client who developed a pulmonary embolism and is currently in the Intensive Care Unit. The nurse in the Intensive Care Unit is interviewing the client and reviewing her history. Which of the

following statements by the client or assessment findings are consistent with the client’s increased risk for developing a pulmonary embolism? Standard Text: Select all that apply. 1. Client states, “I usually smoke two packs of cigarettes each day.” 2. Client states, “The nurse on the surgical unit really wanted me to sit on the side of the bed after surgery and to start walking with him later that evening, but I was so nauseated and in so much pain that I couldn’t.” 3. Client states, “I had an open appendectomy 4 days ago.” 4 cm incision noted to RLQ, staples intact, edges wellapproximated 4. Client states, “I have taken oral contraceptives for the last 7 years.” 5. Client states, “I had some muscle cramping and tenderness in my left leg before they moved me to Intensive Care.” Correct Answer: 1,2,3,4,5 Rationale 1: Client states, “I usually smoke two packs of cigarettes each day.” Cigarette smoke contains nicotine that produces vasoconstriction. Vasoconstriction of blood vessels increases the client’s risk of developing a blood clot or a deep vein thrombosis. Rationale 2: Client states, “The nurse on the surgical unit really wanted me to sit on the side of the bed after surgery and to start walking with him later that evening, but I was so nauseated and in so much pain that I couldn’t.” Ambulation following surgery is very important. Ambulation can reduce blood pooling in the calves and reduce the client’s risk for clot formation. Immobility is a risk factor for blood clot formation. Rationale 3: Client states, “I had an open appendectomy 4 days ago.” 4 cm incision noted to RLQ, staples intact, edges well-approximated . The client’s history of a recent abdominal surgery increases the client’s risk of developing a blood clot. Rationale 4: Client states, “I have taken oral contraceptives for the last 7 years.” Oral contraceptive use is linked to increases risk of blood clot formation because of the way the medication works within the client’s body. Rationale 5: Client states, “I had some muscle cramping and tenderness in my left leg before they moved me to Intensive Care.” Muscle cramping and tenderness in the lower extremity are consistent with a deep vein thrombosis. Global Rationale: Smoking cigarettes can increase the client’s risk for developing a deep vein thrombosis that can turn into a pulmonary embolism. Ambulating after surgery is important to help prevent blood clots from forming. Major surgeries can increase the client’s risk for developing a blood clot. Oral contraceptive use can increase the client’s risk for clotting. The client most likely had a deep vein thrombosis before the pulmonary embolism developed. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.8: Apply critical thinking in selected simulations related to physical assessment of the peripheral vascular system. Question 30 Type: HOTSPOT The client developed a pulmonary embolism. Draw an arrow pointing toward the most distal area of the lower extremity from where the embolism most likely originated.

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The client is more likely to have developed a blood clot within the calf. Blood clots can develop in the popliteal area as well but this site is less distal than the calf. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.8: Apply critical thinking in selected simulations related to physical assessment of the peripheral vascular system.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 19 Question 1 Type: HOTSPOT The nurse is preparing to perform an abdominal assessment. The client states, “Can you point to where my appendix is located?” Draw an arrow to the location of the client’s appendix.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The vermiform appendix is attached to the large intestines at the cecum. Global Rationale: Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen. Question 2 Type: HOTSPOT The nurse is speaking with the client during the focused interview. The client states, “My doctor said that my spleen was enlarged. Where is my spleen?” Draw an arrow to the location of the spleen.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm. Global Rationale: Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen. Question 3 Type: MCMA A client asks the nurse, “What’s the purpose of the liver?” Which of the following statements would be beneficial for the nurse to share with the client? Standard Text: Select all that apply. 1. “It helps you digest fats.” 2. “It is an endocrine and exocrine gland.”

3. “It filters waste from the blood and makes urine.” 4. “It makes some blood clotting substances.” 5. “It can help you store certain vitamins.” Correct Answer: 1,4,5 Rationale 1: “It helps you digest fats.” The liver helps the body digest fats by producing bile. Rationale 2: It is an endocrine and exocrine gland.” The pancreas is an example of an exocrine and endocrine gland. Rationale 3: “It filters waste from the blood and makes urine.” The kidneys filter nitrogen waste from the blood and make urine. Rationale 4: “It makes some blood clotting substances.” The liver makes blood clotting substances. Rationale 5: “It can help you store certain vitamins.” The liver can store certain types of vitamins. Global Rationale: The liver produces and secretes bile for fat breakdown, but also aids in the metabolism of proteins and carbohydrates. It stores some vitamins, helps with blood coagulation, produces antibodies, and detoxifies some harmful substances. The pancreas is an example of an exocrine and endocrine gland. The kidneys filter nitrogen waste from the blood and make urine. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen. Question 4 Type: MCMA The nurse is palpating the right upper quadrant of a client’s abdomen. Which of the following organs may be assessed during this portion of the assessment? Standard Text: Select all that apply. 1. Liver 2. Gallbladder 3. Appendix 4. Spleen 5. Stomach

Correct Answer: 1,2 Rationale 1: Liver. The liver is located in the right upper quadrant. Rationale 2: Gallbladder. The gallbladder is located in the right upper quadrant. Rationale 3: Appendix. The appendix is located in the right lower quadrant. Rationale 4: Spleen. The spleen is located in the left upper quadrant. Rationale 5: Stomach. The stomach is located in the left upper quadrant. Global Rationale: The liver is located in the right upper quadrant. The gallbladder is located in the right upper quadrant. The appendix is located in the right lower quadrant. The spleen is located in the left upper quadrant. The stomach is located in the left upper quadrant. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen. Question 5 Type: MCSA 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. “You are right. We still don’t know the function of the gallbladder.” 2. “It stores bile until it is needed for digestion of fats.” 3. “It destroys old red blood cells.” 4. “It helps you digest carbohydrates by producing enzymes.” Correct Answer: 2 Rationale 1: The gallbladder does have an important function within the body. Rationale 2: The gallbladder is used to store bile that is produced in the liver, until the bile is needed to help digest fats. Rationale 3: The spleen destroys red blood cells. Rationale 4: The pancreas helps the body digest carbohydrates.

Global Rationale: The gallbladder is used to store bile. It is a thin-walled sac that is nestled in a shallow depression on the ventral surface of the liver. The gallbladder releases stored bile into the duodenum when stimulated and thus promotes the emulsification of fats. The main functions of the gallbladder are storing of bile and assisting in the digestion of fats. The spleen destroys red blood cells. The pancreas helps the body digest carbohydrates. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen Question 6 Type: MCMA 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? Standard Text: Select all that apply. 1. Liver 2. Gallbladder 3. Appendix 4. Spleen 5. Stomach Correct Answer: 4,5 Rationale 1: Liver. The liver is located in the right upper quadrant. Rationale 2: Gallbladder. The gallbladder is located in the right upper quadrant. Rationale 3: Appendix. The appendix is located in the right lower quadrant. Rationale 4: Spleen. The spleen is located in the left upper quadrant. Rationale 5: Stomach. The stomach is located in the left upper quadrant. Global Rationale: The spleen is located in the left upper quadrant. The stomach is located in the left upper quadrant. The liver is located in the right upper quadrant. The gallbladder is located in the right upper quadrant. The appendix is located in the right lower quadrant. Cognitive Level: Remembering Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen. Question 7 Type: MCMA The nurse is mapping the client’s abdomen into four quadrants. Which of the following landmarks would the nurse use to perform this assessment? Standard Text: Select all that apply. 1. Umbilicus 2. Midclavicular lines 3. Xiphoid process 4. Lower border of the right ribs 5. Iliac crests Correct Answer: 1,3 Rationale 1: Umbilicus. To obtain four quadrants when mapping the abdomen, extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a horizontal line perpendicular to the first line. Rationale 2: Midclavicular lines. The midclavicular lines are not used to map the client’s abdomen into four quadrants. Rationale 3: Xiphoid process. To obtain four quadrants when mapping the abdomen, extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a horizontal line perpendicular to the first line. Rationale 4: Lower border of the right ribs. The lower border of the right ribs is not used to map the client’s abdomen into four quadrants. Rationale 5: Iliac crests. The iliac crests are not used to map the client’s abdomen into four quadrants. Global Rationale: To obtain four quadrants when mapping the abdomen, extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a horizontal line perpendicular to the first line. The midclavicular lines are not used to map the client’s abdomen into four quadrants. The lower border of the right ribs is not used to map the client’s abdomen into four quadrants. The iliac crests are not used to map the client’s abdomen into four quadrants. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.2: Identify landmarks that guide assessment of the abdomen. Question 8 Type: MCSA The nurse is performing a focused interview with a 79-year-old client. Which of the following statements by the client is unexpected? 1. “I have been having loose stools every day for the last 3 years.” 2. “I know I just don’t drink as much water as I should.” 3. “My belly seems softer and flabbier as I get older.” 4. “My mouth is always dry.” Correct Answer: 1 Rationale 1: Older clients tend to experience constipation as a result of changes in their digestive tracts. Loose stools are an unexpected finding in the older client. Rationale 2: Older clients do not tend to drink as much water as they should to avoid frequent urination. Rationale 3: The older client’s abdomen tends to be softer and more relaxed than in the younger adult. Rationale 4: The older client’s saliva production is decreased resulting in a dry mouth. Global Rationale: Older clients tend to experience constipation as a result of changes in their digestive tracts. Loose stools are an unexpected finding in the older client. Older clients do not tend to drink as much water as they should to avoid frequent urination. The older client’s abdomen tends to be softer and more relaxed than in the younger adult. The older client’s saliva production is decreased resulting in a dry mouth. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.3: Develop questions to be used when completing the focused interview. Question 9 Type: MCMA 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? Standard Text: Select all that apply.

1. “It is a little cool in our examination room; may I turn up the thermostat?” 2. “I’ve been told you are experiencing some pain in the lower left area of your abdomen. I will examine that area first.” 3. “I am going to stand on your left side so I can feel your liver better.” 4. “I’m going to place this drape over you so you don’t feel too exposed during this examination.” 5. “I am going to place this pillow behind your head and this pillow under your knees.” Correct Answer: 2,3 Rationale 1: “It is a little cool in our examination room; may I turn up the thermostat?” The nurse should provide an environment that is warm and comfortable. Rationale 2: “I’ve been told you are experiencing some pain in the lower left area of your abdomen. I will examine that area first.” When a client is experiencing abdominal pain, the nurse should examine that area last. Rationale 3: “I am going to stand on your left side so I can feel your liver better.” Stand on the right side of the client, because the liver and the right kidney are in the right side of the abdomen. Rationale 4: “I’m going to place this drape over you so you don’t feel too exposed during this examination.” Maintain the dignity of the client through appropriate draping techniques. Rationale 5: “I am going to place this pillow behind your head and this pillow under your knees.” The client should be in a supine position with a small pillow placed beneath the head and knees. Global Rationale: When a client is experiencing abdominal pain, the nurse should examine that area last. Stand on the right side of the client, because the liver and the right kidney are in the right side of the abdomen. The nurse should provide an environment that is warm and comfortable. Maintain the dignity of the client through appropriate draping techniques. The client should be in a supine position with a small pillow placed beneath the head and knees. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.4: Explain client preparation for assessment of the abdomen. Question 10 Type: MCMA The nurse is performing an abdominal assessment on a client. During the focused interview, the client stated that he had been experiencing some abdominal pain. As the nurse assesses the client, which of the following behaviors indicates that the client may be experiencing pain or anxiety during the examination? Standard Text: Select all that apply.

1. The client’s respiratory rate is 26 per minute. 2. The client moves away from the nurse’s hands. 3. The client grimaces. 4. The client pulls his knees toward his stomach. 5. The client coughs loudly. Correct Answer: 1,2,3,4 Rationale 1: The client’s respiratory rate is 26 per minute. If the client’s respiratory rate increases during the examination, it can indicate that the client is experiencing pain or anxiety. Rationale 2: The client moves away from the nurse’s hands. The client may move away from the nurse during the examination if the client is experiencing pain. Rationale 3: The client grimaces. Grimacing is a facial expression that can indicate that the client is experiencing pain during the assessment. Rationale 4: The client pulls his knees toward his stomach. The client who exhibits guarding behavior is most likely experiencing pain. Rationale 5: The client coughs loudly. The client who coughs loudly is not necessarily experiencing pain. This is not a typical expression of pain or anxiety. Global Rationale: If the client’s respiratory rate increases during the examination, it may indicate that the client is experiencing pain or anxiety. The client may move away from the nurse during the examination if the client is experiencing pain. Grimacing is a facial expression that can indicate that the client is experiencing pain during the assessment. The client who exhibits guarding behavior is most likely experiencing pain. The client who coughs loudly is not necessarily experiencing pain. This is not a typical expression of pain or anxiety. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.4: Explain client preparation for assessment of the abdomen. Question 11 Type: MCSA 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. Which of the following statements by the client is most consistent with this condition?

1. “I get home so late at night, but I’ve got to stop lying down right after dinner.” 2. “I drink a whole pot of coffee every day.” 3. “I drink 9–12 beers after I get home from work, every day.” 4. “We have been growing green beans in our garden and I think I ate too many the other day.” Correct Answer: 4 Rationale 1: Lying down after meals is often associated with gastroesophageal reflux disorder. Rationale 2: Caffeine intake is associated with irritable bowel syndrome. Rationale 3: Drinking alcohol is associated with irritable bowel syndrome and pancreatitis. Rationale 4: This client is most likely experiencing diverticulitis. 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. Global Rationale: This client most likely is experiencing diverticulitis. 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. Lying down after meals is often associated with gastroesophageal reflux disorder. Caffeine intake is associated with irritable bowel syndrome. Drinking alcohol is associated with irritable bowel syndrome and pancreatitis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 12 Type: MCSA 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 Blumberg’s sign 2. Presence of pain at McBurney’s point

3. Positive Murphy’s sign 4. Positive Psoas sign Correct Answer: 3 Rationale 1: Blumberg’s sign can be elicited when the nurse presses on an area of the abdomen. If the client complains of pain as the nurse pulls back and releases the compressed area, the client has a positive Blumberg’s sign. Rationale 2: Pain at McBurney’s point is associated with appendicitis. This area is located in the right lower quadrant of the client’s abdomen. Rationale 3: Murphy’s sign can be elicited when the client takes a deep breath and holds it while the nurse presses into the right upper quadrant. The nurse is pressing against the gallbladder. Normally, the client will not complain of pain. Rationale 4: With the client in a supine position, the nurse places her left hand just above the level of the client’s right knee. The client is requested to raise the leg to meet the nurse’s hand. Flexion of the hip causes contraction of the psoas muscle and indicates that the client is experiencing peritoneal inflammation, or appendicitis. Global Rationale: Pain with palpation of the liver is indicative of cholecystitis and is noted as a positive Murphy’s sign. The examination should be halted. Blumberg’s sign is sharp pain occurring with the release of a compressed area and is present when the client has peritoneal irritation. Pain at McBurney’s point in the right lower quadrant is associated with appendicitis. Pain that is elicited while flexing the hip is indicative of psoas muscle irritation and is associated with peritoneal inflammation or appendicitis. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 13 Type: MCSA The nurse is assessing the client’s abdomen and notes dullness when percussing over the left lower quadrant. Which of the following questions is most appropriate for the nurse to ask the client at this time? 1. “How much alcohol do you drink?” 2. “Do you have pain after eating?” 3. “When was your last bowel movement?” 4. “Have you ever had splenomegaly?” Correct Answer: 3

Rationale 1: Alcohol can place the client at risk for hepatomegaly and inflammation of the liver. Rationale 2: Pain after eating may indicate that some sort of upper gastrointestinal problem has developed. Rationale 3: Stool in the distal portion of the client’s colon can produce dullness upon percussion of the left lower quadrant. Rationale 4: Splenomegaly would produce dullness while percussing the left upper quadrant. Global Rationale: Percussion over the abdomen produces tympany, and dullness is heard over the solid organs such as the liver and spleen. Dullness may also indicate an enlarged uterus, distended urinary bladder or ascites. Dullness in the left lower quadrant may also indicate the presence of stool in the colon. Significant alcohol consumption may be associated with possible liver enlargement. The nurse would be able to percuss the liver in the right upper quadrant. Pain after eating is more likely to be associated with an upper gastrointestinal problem. Splenomegaly is associated with dullness while percussing the client’s left upper quadrant. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 14 Type: MCMA 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? Standard Text: Select all that apply. 1. “I’m going to talk to my doctor about a nicotine patch.” 2. “I can do all of this stuff you’re talking about as long as I don’t have to give up my beer.” 3. “I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle.” 4. “The root of this problem is that I just sleep too much.” 5. “I told my wife to stop making serving me all of those vegetables.” Correct Answer: 2,4,5 Rationale 1: “I’m going to talk to my doctor about a nicotine patch.” Smoking cigarettes is associated with an increased risk for developing esophagitis. Rationale 2: “I can do all of this stuff you’re talking about as long as I don’t have to give up my beer.” Alcohol can increase the client’s risk for developing esophagitis.

Rationale 3: “I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle.” Eating foods that are either too hot or too cold can be irritating to the tissue and can result in esophagitis. Rationale 4: “The root of this problem is that I just sleep too much.” Sleeping “too much” is not associated with the development of esophagitis. Rationale 5: “I told my wife to stop making serving me all of those vegetables.” Eating vegetables is not associated with the development of esophagitis. Global Rationale: Alcohol can exacerbate and is an established risk factor for the development of esophagitis. Sleeping “too much” is not associated with the development of esohagitis. Eating vegetables is not associated with the development of esophagitis. Smoking cigarettes is associated with an increased risk for developing esophagitis. Eating foods that are either too hot or too cold can be irritating to the tissue and can result in esophagitis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 15 Type: MCSA 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. Cholecystitis 2. Duodenal ulcer 3. Gastritis 4. Pancreatitis Correct Answer: 1 Rationale 1: Right upper quadrant pain that radiates to the right scapula is characteristic of cholecystitis. The pain usually occurs after the client eats a fatty meal. Rationale 2: Duodenal ulcers cause aching, gnawing, epigastric pain. This is associated with stress and NSAID use. Rationale 3: Gastritis causes epigastric pain. It is associated with NSAID use, alcohol abuse, stress, infection, H. pylori infection, and/ or autoimmune responses.

Rationale 4: Pancreatitis produces upper abdominal, knifelike, deep epigastric or umbilical area pain. It is associated with alcohol abuse, use of acetaminophen, and infection. Global Rationale: Right upper quadrant pain that radiates to the right scapula is characteristic of cholecystitis. The pain usually occurs after the client eats a fatty meal. Duodenal ulcers cause aching, gnawing, epigastric pain. It is associated with stress and NSAID use. Gastritis causes epigastric pain. It is associated with NSAID use, alcohol abuse, stress, infection, H. pylori infection, and autoimmune responses. Pancreatitis produces upper abdominal, knifelike, deep epigastric or umbilical area pain. It is associated with alcohol abuse, use of acetaminophen, and infection. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 16 Type: MCSA The nurse is performing an abdominal assessment. After percussing the abdomen, the nurse notes that the liver span is approximately 9 centimeters. Which of the following ways is an appropriate way to document this finding? 1. Hepatomegaly 2. A normal finding 3. Related to recent diagnosis of chronic bronchitis 4. Presence of ascites Correct Answer: 2 Rationale 1: Hepatomegaly would be associated with a liver span greater than 10 centimeters. Rationale 2: This is a normal finding. Rationale 3: The client with chronic bronchitis may have a liver that is displaced downward within the abdomen. Rationale 4: The client with ascites may have a liver that is displaced upward within the abdomen. Global Rationale: The liver span is the distance between the lower and upper border of the liver. It should be approximately 5 to 10 centimeters (2 to 4 inches). The liver in this situation is not enlarged, and it would be inappropriate for the nurse to determine that client has an enlarged liver (hepatomegaly). The client with chronic bronchitis may have a liver that is displaced downward within the abdomen. The client with ascites may have a liver that is displaced upward within the abdomen. Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 17 Type: MCSA The nurse is completing an abdominal assessment and is percussing over the left side of the upper portion of the client’s abdomen over the area of the stomach. The client states, “I haven’t had my breakfast, yet.” The nurse would expect to find which of the following during this part of the examination? 1. Dullness 2. Flatness 3. Tympany 4. Hyperesonance Correct Answer: 3 Rationale 1: Dullness suggests a mass within the stomach. It is a short high-pitched sound heard over solid organs, masses, or fluid-filled structures. Rationale 2: Flat sounds are short and abrupt. They are heard over bone or muscle. Rationale 3: Tympany is the normal sound that can be heard when an air-filled structure is percussed. Rationale 4: Hyperesonance is a hollow sound that is louder than tympany. Hyperresonance is louder than tympany and is heard over air-filled or distended intestines. Global Rationale: Tympany is a loud, drum-like sound heard over structures filled with air, such as the stomach or air in the intestines. Dullness is a soft to moderate thud-like sound heard over solid organs such as the liver. If heard over the stomach, dullness suggests a stomach mass and also may be heard after a large meal. Flatness is a soft, flat sound heard over muscle or bone. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 18 Type: MCSA

The nurse is documenting the findings of an abdominal assessment on a client and documents the following information, “pain noted during palpation at McBurney’s point.” In which of the following ways did the nurse elicit this response? 1. The nurse lightly palpated the around the client’s umbilicus. 2. The nurse pressed into the client’s abdomen and then pulled his hand back quickly. 3. The nurse palpated over the client’s spleen. 4. The nurse palpated the area between the client’s ileum and umbilicus in the client’s right lower quadrant. Correct Answer: 4 Rationale 1: The nurse should be able to lightly palpate around the umbilicus without any complaints of pain by the client. Rationale 2: This procedure is used to elicit the Blumberg’s sign. Rationale 3: Palpation over the client’s spleen may be used to determine if the client has splenomegaly. Rationale 4: The nurse can palpate over McBurney’s point to determine if the client has developed appendicitis. Global Rationale: McBurney’s point is located 2.5 to 5.1 centimeters above the anterosuperior iliac spine, on a line between the ileum and the umbilicus. When the client experiences pain at this site with palpation it is referred to as a positive Rovsing’s sign, which is suggestive of peritoneal irritation that is most frequently associated with appendicitis. Pain with palpation over the umbilicus may indicate an infectious process such as diverticulitis. A hernia may be palpated or visualized during the nurse’s inspection of the client’s abdomen. Pain as an area is compressed and then is allowed to decompress is known as a positive Blumberg’s sign. This sign occurs in clients with peritoneal irritation. Normally, the client should feel pressure but no pain as the nurse palpates the client’s spleen. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 19 Type: MCSA The client states, “No one will let me eat or drink anything until after my test and it’s been 9 hours since I last ate anything!” While auscultating the client’s abdomen the nurse hears frequent bowel sounds. In which of the following ways should the nurse accurately document this finding? 1. Borborygmi present 2. Hypoactive bowel sounds present

3. Bruit present 4. Friction rub present Correct Answer: 1 Rationale 1: Borborygmi are hyperactive bowel sounds. Rationale 2: Hypoactive bowel sounds are not normally auscultated in clients who are merely hungry. They are more often auscultated in clients who have developed a bowel obstruction or who have had a major abdominal surgery. Rationale 3: Bruits can be auscultated over blood vessels. Rationale 4: Friction rubs are associated with the rubbing together of abdominal organs or organs that may be rubbing on the peritoneum. Global Rationale: Normal bowel sounds occur every 5 to 15 seconds. Borborygmi are hyperactive bowel sounds that are most often auscultated in clients who have not eaten recently. Hypoactive bowel sounds are most often auscultated in clients who have had abdominal surgery or who have a bowel obstruction. A bruit is a pulsing, blowing sound that can be auscultated over arteries. A friction rub is a rough, grating sound caused by the rubbing together of organs or an organ rubbing on the peritoneum. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 20 Type: MCMA The nurse is assessing a client in the Emergency Department with complaints of right lower quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign. The nurse accurately suspects that which of the following conditions or problems may be occurring? Standard Text: Select all that apply. 1. Constipation 2. Appendicitis 3. Cholecystitis 4. Small bowel obstruction 5. Peritonitis

Correct Answer: 2,5 Rationale 1: Constipation. Constipation is not typically associated with a positive psoas sign. Rationale 2: Appendicitis. A positive psoas sign is indicative of irritation of the psoas muscle and is associated with appendicitis. Rationale 3: Cholecystitis. The client with cholecystitis may exhibit a positive Murphy’s sign. Rationale 4: Small bowel obstruction. The client with a small bowel obstruction may exhibit abnormal bowel sounds. Rationale 5: Peritonitis. A positive psoas sign is indicative of irritation of the psoas muscle and is associated with peritoneal inflammation. Global Rationale: A positive psoas sign is indicative of irritation of the psoas muscle and is associated with peritoneal inflammation or appendicitis. Constipation is not typically associated with a positive psoas sign. The client with cholecystitis may exhibit a positive Murphy’s sign. The client with a small bowel obstruction may exhibit abnormal bowel sounds. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 21 Type: MCSA The nurse is auscultating the abdomen of a client for vascular sounds with the bell of the stethoscope. The nurse hears a soft, continuous humming sound. The nurse suspects that dysfunction of which of the following organs ultimately may have resulted in the production of this sound? 1. Stomach 2. Spleen 3. Pancreas 4. Liver Correct Answer: 4 Rationale 1: Dysfunction in the client’s stomach did not result in this type of sound. Rationale 2: Dysfunction in the client’s spleen most likely did not result in this type of sound. Rationale 3: Dysfunction in the client’s pancreas did not result in this type of sound.

Rationale 4: The nurse is hearing an abnormal abdominal sound called a venous hum, which is indicative of portal hypertension. Portal hypertension is the result of liver congestion. Global Rationale: The nurse is hearing an abnormal abdominal sound called a venous hum, which is indicative of portal hypertension. Portal hypertension is the result of liver congestion. Dysfunction in the client’s stomach did not result in this type of sound. Dysfunction in the client’s spleen most likely did not result in this type of sound. Dysfunction in the client’s pancreas did not result in this type of sound. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 22 Type: MCMA 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? Standard Text: Select all that apply. 1. Obtain stool specimen for occult blood. 2. Measure the client’s abdominal girth. 3. Obtain stool specimen for culture and sensitivity. 4. Bilateral leg measurements. 5. Percuss the abdomen at midline. Correct Answer: 2,5 Rationale 1: Obtain stool specimen for occult blood. The nurse would not necessarily suspect that the client had occult blood in the stool. Rationale 2: Measure the client’s abdominal girth. When ascites is suspected, the abdominal girth should be measured to obtain a baseline for further evaluation. Rationale 3: Obtain stool specimen for culture and sensitivity. The nurse does not need to send a stool specimen for a culture and sensitivity. This would indicate that the nurse believed that the client had an infection within the gastrointestinal tract. Rationale 4: Bilateral leg measurements. The nurse does not necessarily need to measure the circumferences of the client’s legs for edema.

Rationale 5: Percuss the abdomen at midline. The nurse would need to assess the client’s abdomen for tympany during percussion. This is a sign of ascites. Global Rationale: The nurse should measure the client’s abdominal girth to obtain baseline information for further comparisons. The nurse should percuss the abdomen at midline for tympany because this is a sign of ascites. The nurse would not necessarily suspect that the client had occult blood in the stool. The nurse does not need to send a stool specimen for a culture and sensitivity. This would indicate that the nurse believed that the client had an infection within the gastrointestinal tract. The nurse does not necessarily need to measure the circumferences of the client’s legs for edema. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 23 Type: FIB The client’s ideal body weight is 125 pounds. The nurse is calculating the client’s weight in order to determine if the client is obese. The client weighs 155.5 kilograms. Calculate the client’s weight in pounds. Round to the nearest whole number. pounds Standard Text: Correct Answer: 342 pounds Rationale: The client weighs more than 100 pounds over the ideal body weight. There are 2.2 pounds in 1 kilogram. The client’s weight in pounds is 342.1 pounds and when rounded to the nearest whole number, the client’s weight is 342 pounds. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen. Question 24 Type: MCSA The nurse is performing an abdominal assessment on an infant. The nurse notes that the umbilicus is bulging and has been displaced slightly to the left of midline. The nurse would suspect that the infant has developed which of the following conditions?

1. Infection 2. Umbilical hernia 3. Ventral hernia 4. Hiatal hernia Correct Answer: 2 Rationale 1: This is not a sign of an infection. Rationale 2: This is a normal finding in an infant. A protruding or displaced umbilicus is a normal variation in pregnant females. An umbilical hernia occurs at the umbilicus and allows the intestines or other abdominal structures to protrude through the abdominus rectus muscle and come closer to the skin. Rationale 3: Ventral hernias occur in previous incisional sites. Rationale 4: A hiatal hernia is due to a weakening in the diaphragm that allows a portion of the stomach and the esophagus to move into the thoracic cavity. This type of hernia is more commonly found in adults than in children. Global Rationale: An umbilical hernia occurs at the umbilicus and allows the intestines or other abdominal structures to protrude through the abdominus rectus muscle and come closer to the skin. This is not a normal finding in an infant. A protruding or displaced umbilicus is a normal variation in pregnant females. Ventral hernias occur in previous incisional sites. A hiatal hernia is due to a weakening in the diaphragm that allows a portion of the stomach and the esophagus to move into the thoracic cavity. This type of hernia is more commonly found in adults than in children. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 25 Type: SEQ The nurse is performing an abdominal assessment on the client. Rank the following steps of assessment in the order that they should be performed. Standard Text: Click and drag the options below to move them up or down. Choice 1. Percuss the abdomen. Choice 2. Visualize the quadrants of the abdomen.

Choice 3. Palpate the abdomen. Choice 4. Auscultate the abdomen. Choice 5. Encourage the client to void. Correct Answer: 5,2,4,1,3 Rationale 1: The first step is for the nurse to encourage the client to void prior to the abdominal assessment. Rationale 2: The second step is for the nurse to visualize the quadrants of the client’s abdomen. Rationale 3: The third step is for the nurse to auscultate the abdomen. Rationale 4: The fourth step is for the nurse to percuss the abdomen. Rationale 5: The fifth step is for the nurse to palpate the abdomen. Global Rationale: The client should be encouraged to void prior to the abdominal assessment. Physical assessment of the abdomen requires the use of inspection, auscultation, percussion, and palpation. This order differs from that of physical assessment of other systems. The nurse should remember to auscultate after inspection. Delaying percussion and palpation prevents disturbance of the normal bowel sounds. During each of the procedures the nurse is gathering data related to problems with underlying abdominal organs and structures. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.7: Describe the variation in techniques required for assessment of the abdomen. Question 26 Type: MCSA The nurse is caring for a client with hepatitis A virus. The client requests information about how the virus is transmitted. Which of the following statements by the nurse is the best response? 1. “This virus is transmitted by sexual contact with someone who already has been infected with this virus.” 2. Most likely, you ate something that was contaminated with the virus.” 3. “It is spread by blood transfusions.” 4. “Have you ever injected an illegal drug?” Correct Answer: 2 Rationale 1: Sexual contact with someone who is infected with a specific virus resulting in hepatitis is most closely associated with developing hepatitis B or D.

Rationale 2: Eating food that is contaminated with hepatitis A virus may result in the client developing clinical manifestations associated with hepatitis A virus. Rationale 3: Blood product transfusions can result in the transmission of hepatitis B, C, or D viruses. Rationale 4: Injecting illegal drugs can result in the transmission of hepatitis B, C, or D viruses. Global Rationale: Educating clients about hepatitis A, B, and C viruses is included in the Healthy People 2020 objectives. Education about the viruses can help reduce transmission. Hepatitis A virus is transmitted through enteric routes and is usually the result of eating food that was contaminated with the virus. Hepatitis B virus is transmitted parenterally, sexually, or perinatally. Hepatitis C virus is transmitted via blood and blood products, parenterally, and through other unknown factors. Hepatitis B, C, and D viruses can be transmitted parentally and the client may be infected while injecting illegal drugs. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.8: Discuss the objectives in Healthy People 2020 as they relate to issues of the abdomen and gastrointestinal system. Question 27 Type: MCSA The pediatric nurse is preparing an educational presentation for parents of school-aged children regarding hepatitis. The nurse wishes to focus on the most common type that occurs in children. Which of the following types of hepatitis viruses would the nurse choose to focus on during this presentation? 1. Hepatitis A virus 2. Hepatitis B virus 3. Hepatitis C virus 4. Hepatitis D virus Correct Answer: 1 Rationale 1: Hepatitis A virus is the most common type of virus resulting in hepatitis that develops in children. Rationale 2: Hepatitis B virus is transmitted parenterally, sexually, or perinatally. Rationale 3: Hepatitis C virus is transmitted through blood and blood products, parenterally, and through unknown ways. Rationale 4: Hepatitis D virus is transmitted parenterally, sexually, and perinatally.

Global Rationale: Hepatitis A occurs most frequently in children and young adults. Hepatitis B, C, and D virus transmission seems unrelated to specific age groups and is most closely associated with specific risk factors or behaviors. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.8: Discuss the objectives in Healthy People 2020 as they relate to issues of the abdomen and gastrointestinal system. Question 28 Type: MCMA The student nurses are preparing educational presentations regarding the Healthy People 2020 objectives. The nursing instructor is reviewing the topics of their presentations. Which of the following topics are appropriate and related to the objectives? Standard Text: Select all that apply. 1. Educate pregnant women regarding the importance of small, more frequent dry meals throughout the day to reduce nausea and vomiting. 2. Educate Asian men about the importance of avoiding alcohol because this is a population that is prone to alcohol abuse. 3. Educate people who are anticipating traveling to India, Asia, Africa, or Central America about ways to reduce their risk of becoming infected with hepatitis E virus. 4. Educate immunocompromised populations and those caring for them about the importance of safe food handling. 5. Educate people about the relationship between regular, thorough oral hygiene practices and good nutrition. Correct Answer: 1,3,4,5 Rationale 1: Educate pregnant women regarding the importance of small, more frequent dry meals throughout the day to reduce nausea and vomiting. Pregnant women who eat smaller, dry meals throughout the day are less likely to experience nausea and vomiting than women who eat fewer, larger meals during the day. Rationale 2: Educate Asian men about the importance of avoiding alcohol because this is a population that is prone to alcohol abuse. Caucasian and Hispanic populations are more prone to alcohol abuse than Asians. Rationale 3: Educate people who are anticipating traveling to India, Asia, Africa, or Central America about ways to reduce their risk of becoming infected with hepatitis E virus. People who travel to Indian, Asia, Africa, or Central America are more likely to become infected with hepatitis E virus.

Rationale 4: Educate immunocompromised populations and those caring for them about the importance of safe food handling. Immunocompromised clients are more prone to developing foodborne illnesses. Safe food handling when preparing food for these clients is very important. Rationale 5: Educate people about the relationship between regular, thorough oral hygiene practices and good nutrition. Poor oral hygiene is associated with malnutrition. Global Rationale: Pregnant women who eat smaller, dry meals throughout the day are less likely to experience nausea and vomiting than women who eat fewer, larger meals during the day. People who travel to Indian, Asia, Africa, or Central America are more likely to become infected with hepatitis E virus. Immunocompromised clients are more prone to developing foodborne illnesses. Safe food handling when preparing food for these clients is very important. Poor oral hygiene is associated with malnutrition. Caucasian and Hispanic populations are more prone to alcohol abuse than Asians. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.8: Discuss the objectives in Healthy People 2020 as they relate to issues of the abdomen and gastrointestinal system. Question 29 Type: MCMA The nurse is interviewing a 79-year-old Hispanic client with complaints of recent weight loss, anorexia, and epigastric pain. The client reports recent use of “mints” for stomach upset. Which of the following interventions are appropriate? Standard Text: Select all that apply. 1. Schedule the client for an endoscopy as ordered. 2. Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider. 3. Educate the client regarding Helicobacter pylori infections. 4. Discuss the importance of using over-the-counter aspirin for mild pain relief. 5. Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer. Correct Answer: 1,2,3 Rationale 1: Schedule the client for an endoscopy as ordered. The client should be scheduled for an endoscopy as ordered by the healthcare provider. This is a common diagnostic test used for clients with suspected peptic ulcers.

Rationale 2: Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider. The client should take antacids after meals and at bedtime. Rationale 3: Educate the client regarding Helicobacter pylori infections. The client should be educated about the most common cause of peptic ulcers, which is an infection due to Helicobacter pylori (H. pylori). H. pylori is a bacteria that results in an infection that causes more than 90% of peptic ulcers. It infects almost two thirds of the world’s population and is more prevalent in the elderly, African Americans, Hispanics, and those in lower socioeconomic groups. Rationale 4: Discuss the importance of using over-the-counter aspirin for mild pain relief. The client should avoid aspirin products because they can make the symptoms worse. Rationale 5: Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer. The client can avoid spicy foods but not because this is the most common cause of peptic ulcers. The spicy foods may aggravate the client’s condition. In the past, it was believed that ulcers were caused by stress or eating too much acidic food. Now it is known that this is not true. Global Rationale: The client should be scheduled for an endoscopy as ordered by the healthcare provider. This is a common diagnostic test used for clients with suspected peptic ulcers. The client should take antacids after meals and at bedtime. The client should be educated about the most common cause of peptic ulcers, which is an infection due to Helicobacter pylori (H. pylori). H. pylori is a bacteria that results in an infection that causes more than 90% of peptic ulcers. It infects almost two thirds of the world’s population and is more prevalent in the elderly, African Americans, Hispanics, and those in lower socioeconomic groups. The client should avoid aspirin products because they can make the symptoms worse. The client can avoid spicy foods but not because this is the most common cause of peptic ulcers. The spicy foods may aggravate the client’s condition. In the past, it was believed that ulcers were caused by stress or eating too much acidic food. Now it is known that this is not true. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.9: Apply critical thinking in selected simulations related to assessment of the abdomen. Question 30 Type: MCMA The client is 14 years old and is visiting the healthcare provider’s office with abdominal pain. The client states, “The pain is sort of all over my belly. I can’t really find one place that hurts more than another area.” Based on the nurse’s understanding about disorders of abdomen and associated symptomatology, the nurse will expect to discover that which of the following nursing diagnoses can most likely be applied to this client’s plan of care? Standard Text: Select all that apply. 1. Acute pain 2. Hypothermia 3. Diarrhea

4. Altered urinary elimination 5. Altered nutrition, less than body requirements Correct Answer: 1,3,5 Rationale 1: Acute pain. The client is currently experiencing diffuse acute pain and this is a common complaint for the client with ulcerative colitis. Rationale 2: Hypothermia. It would be unusual for the client with ulcerative colitis to complain of hypothermia or have a lowered body temperature. Rationale 3: Diarrhea. The client with ulcerative colitis will commonly experience diarrhea. Rationale 4: Altered urinary elimination. The client with ulcerative colitis will not typically experience altered urinary elimination. Rationale 5: Altered nutrition, less than body requirements. The client with ulcerative colitis may experience weight loss. Global Rationale: This client is most likely experiencing clinical manifestations associated with ulcerative colitis. Ulcerative colitis is a recurrent inflammatory process causing ulcer formation in the lower portions of the large intestine and rectum. This condition is common in adolescents and young adults. The client is currently experiencing diffuse acute pain. The client will commonly complain of diarrhea. The client may experience weight loss. It would be unusual for the client to complain of hypothermia or have a lowered body temperature. The client with ulcerative colitis will not typically experience altered urinary elimination. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.9: Apply critical thinking in selected simulations related to assessment of the abdomen.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 20 Question 1 Type: MCSA The nurse is interviewing an elderly client in the clinic that reports incontinence. Numerous attempts in the recent past have been unsuccessful in helping to control the problem. A priority nursing diagnosis to consider for this client is which of the following? 1. Skin integrity impairment 2. Self-care deficit 3. Self-esteem, situational-low 4. Infection Correct Answer: 3 Rationale 1: Skin integrity impairment is of concern, but there is no data in this scenario to indicate that it is the highest priority nursing diagnosis. Rationale 2: There is no data in this situation to indicate any self-care deficit issues. Rationale 3: Since the client has had no success in controlling the incontinence after repeated attempts, this client is at a high risk for situational low self-esteem. Rationale 4: There is no data in this scenario to indicate a risk for infection. Global Rationale: Clients suffering from incontinence are at increased risk for social isolation, self-esteem disturbance, and other psychosocial problems. There is no data to support a self-care deficit; the information available is that this client has tried to implement measures to treat the problem. The client is certainly at risk for infection and skin integrity impairment, but these two are not active at this time. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 20.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 2 Type: MCMA The nurse is interviewing a client regarding urinary health. Which questions would the nurse include during the collection of subjective data?

Standard Text: Select all that apply. 1. “Do you have difficulty starting your stream of urine?” 2. “After you urinate, does your bladder feel full or empty?” 3. “Do you ever have an accident or wet yourself when you sneeze?” 4. “Do you have to hurry to the bathroom when you have to urinate?” 5. “Do you know the results of your recent urine analysis tests?” Correct Answer: 1,2,3,4,5 Rationale 1: “Do you have difficulty starting your stream of urine?” Difficulty starting a stream usually indicates prostate disease in the male client. Rationale 2: “After you urinate, does your bladder feel full or empty?” Urinary retention, or holding residual urine in the bladder after voiding, creates the sensation that the client is unable to empty the bladder and may contribute to the development of infection. Rationale 3: “Do you ever have an accident or wet yourself when you sneeze?” Stress incontinence is most likely the cause of the client experiencing partial or complete incontinence when sneezing, coughing, and laughing due to loss of muscle control. Rationale 4: “Do you have to hurry to the bathroom when you have to urinate?” Urge incontinence is most likely the cause of the client experiencing partial or complete incontinence if the client is consistently unable to reach the bathroom in time, and is due to loss of muscle control. Rationale 5: “Do you know the results of your recent urine analysis tests?” Determining the client’s knowledge of their urine health is important for ensuring client involvement in the plan of care. Global Rationale: Urinary retention or holding residual urine in the bladder after voiding creates the sensation that the client is unable to empty the bladder and may contribute to the development of infection. Difficulty starting a stream usually indicates prostate disease in the male client. Stress incontinence and urgency occur when there is loss of muscle control over urination. Determining the client’s knowledge of their urine health is important for ensuring client involvement in the plan of care. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.3: Develop questions to be used when completing the focused interview. Question 3 Type: MCSA The nurse is collecting a urine specimen from a client and notes the urine is foamy and amber in color. The nurse would suspect which of the following in this situation?

1. Kidney stones 2. Urinary tract infection 3. Prostate disease 4. Liver disease Correct Answer: 4 Rationale 1: Pain is the primary symptom for the client with kidney stones. The pain may radiate and is variable in location and severity. Other symptoms include spasms, nausea, vomiting, pain on urination, frequency and urgency of urination, and gross hematuria. Rationale 2: If a urinary tract infection is present, the client may complain of pain during urination with urgency, frequency, dribbling, pain upon urination, and suprapubic or lower back pain. Hematuria, as well as cloudy and foul-smelling urine may also accompany a urinary tract infection. Rationale 3: Prostate disease may make it difficult for male clients to begin or maintain their urine stream. Rationale 4: Foamy, amber-colored urine frequently is an indication of hepatic illness (liver disease). Global Rationale: Foamy, amber-colored urine may indicate the presence of hepatic illness (liver disease). If a urinary tract infection is present, the client may complain of pain during urination with urgency, frequency, dribbling, pain upon urination, and suprapubic or lower back pain. Hematuria, as well as cloudy and foul-smelling urine may also accompany a urinary tract infection. Prostate disease may make it difficult for male clients to begin or maintain their urine stream. Pain is the primary symptom for the client with kidney stones. The pain may radiate and is variable in location and severity. Other symptoms include spasms, nausea, vomiting, pain on urination, frequency and urgency of urination, and gross hematuria. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 20.6: Differentiate normal from abnormal findings in physical assessment of the urinary system. Question 4 Type: MCSA The nurse is caring for a baby with newly diagnosed renal disease. The nurse would anticipate diagnostic tests to evaluate functioning of which of the following sytems to be the highest priority? 1. Ears 2. Heart 3. Lungs

4. Joints Correct Answer: 1 Rationale 1: The ears and kidneys develop at the same time in utero. Congenital deafness is frequently associated with renal disease; therefore, the auditory function of the baby with known renal disease would be important to assess because of the embryonic development. Rationale 2: Even though all body systems should be assessed to make sure their function is normal, the heart would not be the highest priority system since congenital deafness is frequently associated with renal disease due to the ears and kidneys developing at the same time in utero. Rationale 3: Even though all body systems should be assessed to make sure their function is normal, the lungs would not be the highest priority system since congenital deafness is frequently associated with renal disease due to the ears and kidneys developing at the same time in utero. Rationale 4: Even though all body systems should be assessed to make sure their function is normal, the joints would not be the highest priority system since congenital deafness is frequently associated with renal disease due to the ears and kidneys developing at the same time in utero. Global Rationale: The ears and kidneys develop at the same time in utero. Congenital deafness is associated with renal disease. Even though all other systems would be assessed to make sure their function is normal, the auditory function of the baby with known renal disease would be important to assess because of the embryonic development. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 5 Type: MCSA The nurse is admitting a client with constant, severe flank pain, spasms, nausea and vomiting, and oliguria. The client states that the pain was initially intermittent and radiated from the low back to the lower quadrants of the abdomen. The nurse’s next action is to: 1. administer pain medication. 2. notify the healthcare provider immediately. 3. obtain a urine specimen for culture. 4. complete the assessment. Correct Answer: 2

Rationale 1: Administering pain medication would not be appropriate since the client’s symptoms indicate hydroureter. Hydroureter is a complication that occurs when a renal calculus (kidney stone) moves into the ureter and blocks and dilates the ureter. Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function; therefore, the healthcare provider should be notified immediately. Rationale 2: Hydroureter is a complication that occurs when a renal calculus (kidney stone) moves into the ureter and blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea and vomiting, and diminished volume of urine (oliguria). Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function; therefore, the healthcare provider should be notified immediately. Rationale 3: Obtaining a urine specimen for culture would not be appropriate since the client’s symptoms indicate hydroureter. Hydroureter is a complication that occurs when a renal calculus (kidney stone) moves into the ureter and blocks and dilates the ureter. Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function; therefore, the healthcare provider should be notified immediately. Rationale 4: Completing the assessment would not be appropriate since the client’s symptoms indicate hydroureter. Hydroureter is a complication that occurs when a renal calculus (kidney stone) moves into the ureter and blocks and dilates the ureter. Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function; therefore, the healthcare provider should be notified immediately. Global Rationale: Hydroureter is a complication that occurs when a renal calculus moves into the ureter and blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea and vomiting, and diminished volume of urine (oliguria). Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function, and medical collaboration should be initiated immediately. All other options would not be appropriate in an emergency situation. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.6: Differentiate normal from abnormal findings in physical assessment of the urinary system. Question 6 Type: MCSA The nurse is palpating the left flank area and feels a sharp edge with definite delineated margins. The nurse is most likely palpating which of the following? 1. An enlarged spleen 2. An enlarged kidney 3. The colon 4. A distended bladder Correct Answer: 1

Rationale 1: The left kidney and the spleen lie in the left upper quadrant of the abdomen and can be palpated in the flank area if enlarged. An enlarged kidney feels smooth and rounded, whereas an enlarged spleen feels sharper with a more delineated edge. Rationale 2: The left kidney and the spleen lie in the left upper quadrant of the abdomen and can be palpated in the flank area if enlarged; however, the kidney would feel smooth and rounded if palapated. Rationale 3: The colon normally cannot be palpated. Rationale 4: A distended bladder would be palpated in the symphysis pubis area. Global Rationale: An enlarged kidney feels smooth and rounded, whereas an enlarged spleen feels sharper with a more delineated edge. Both organs lie in the left upper quadrant of the abdomen. Usually the kidneys are not palpable, but may be if enlarged. The colon should not be palpable, and the bladder is in the area over the symphysis pubis. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.2: Identify landmarks that guide assessment of the urinary system. Question 7 Type: MCMA The nurse is assessing a client admitted for oliguria of unknown origin. During the admission, the client asks the nurse what affects urinary output. The nurse would list which of the following when responding? Standard Text: Select all that apply. 1. Bladder size 2. Bowel patterns 3. Medications 4. Client temperature 5. Fluid intake Correct Answer: 1,3,4,5 Rationale 1: Bladder size. Bladder size affects the amount and number of times a client voids. An adult may void five or six times per day in amounts averaging 100 to 400ml. Rationale 2: Bowel patterns. Bowel pattern generally has no affect on urinary output.

Rationale 3: Medications. Various medications may affect the total urinary output. For example, diuretics will increase the amount urinary output. Rationale 4: Client temperature. The client’s temperature may affect the total urinary output. During times of fever the urinary output may decrease as a result of diaphoresis or dehydration. Rationale 5: Fluid intake. The amount of fluid intake should closely correlate with the amount of fluid the client eliminates. When the amounts do not closely correlate, the reason for the difference must be investigated as it could be indicative of a potential problem. Global Rationale: Bowel pattern does not usually affect the amount of urinary output. Factors that influence the number of times and the amount of urine that a client voids include the size of the bladder, medications, the client’s temperature, and fluid intake. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.1: Describe the anatomy and physiology of the urinary system. Question 8 Type: MCSA Since returning from surgery the client has not voided for 8 hours; therefore, the nurse determines it is necessary to assess the client for bladder distention. The nurse would palpate for bladder distention with the client in which of the following positions? 1. Supine with only a small pillow under their head. 2. Prone position 3. Sitting in bed at a 45-degree angle 4. Lying in a left lateral position Correct Answer: 1 Rationale 1: The bladder, when empty, is usually not palpable. As the bladder fills, the fundus can be palpated anywhere between the symphysis pubis to the level of the umbilicus When distended the bladder will feel firm, smooth, symmetric, and non-tender. Lying supine with a small pillow under the head will allow for proper palpation of a distended bladder. Rationale 2: Supine position is lying face down so it would be impossible to palpate the bladder. Rationale 3: Sitting at a 45-degree angle would not allow proper palpation of the bladder. Rationale 4: Lying in a left lateral position would not allow proper palpation of the bladder.

Global Rationale: The bladder, when empty, is usually not palpable. As the bladder fills, the fundus can be palpated anywhere between the symphysis pubis to the level of the umbilicus When distended, the bladder will feel firm, smooth, symmetric, and non-tender. Lying supine with a small pillow under the head will allow for proper palpation of a distended bladder. The other positions will not allow proper palpation of the bladder. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.4: Explain client preparation for assessment of the urinary system Question 9 Type: MCSA The nurse is percussing over the client’s symphysis pubis area and notes a dull tone. The nurse understands that this represents which of the following? 1. The right kidney 2. A full bladder 3. A bladder tumor 4. Air trapped in the intestines Correct Answer: 2 Rationale 1: While percussion of the kidney does produce a dull tone, the right kidney would lie superior and to the right of the bladder, rather than in the symphysis pubis area. Rationale 2: The bladder lies in the symphysis pubis area and percussion over a full bladder produces a dull tone. Rationale 3: The nurse would be unable to determine presence of a bladder tumor by percussion. Rationale 4: Air trapped in the intestines would produce tympany. Global Rationale: Percussion over a full bladder produces a dull tone. An empty bladder sits low in the pelvic cavity behind the symphysis pubis, and would be difficult to percuss. Percussion over one of the kidneys would also produce a dull tone, but these organs lie lateral and superior to the bladder. Air trapped in the intestines would produce tympany. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.5: Describe the techniques required for assessment of the urinary system. Question 10

Type: MCMA A client presents with a medical diagnosis of uremia. The nurse expects to find which symptoms? Standard Text: Select all that apply. 1. Itching 2. Weight loss 3. Altered mental status 4. Fluid retention 5. Insomnia Correct Answer: 1,2,3,4 Rationale 1: Itching. Uremia is a classic sign of renal failure in which urea and other nitrogen-containing waste products are found in the blood. Common symptoms include itching, weight loss, altered mental status, and fluid retention. Fatigue rather than insomnia is another symptom. Rationale 2: Weight loss. Uremia is a classic sign of renal failure in which urea and other nitrogen-containing waste products are found in the blood. Common symptoms include itching, weight loss, altered mental status, and fluid retention. Rationale 3: Altered mental status. Uremia is a classic sign of renal failure in which urea and other nitrogencontaining waste products are found in the blood. Common symptoms include itching, weight loss, altered mental status, and fluid retention. Rationale 4: Fluid retention. Uremia is a classic sign of renal failure in which urea and other nitrogen-containing waste products are found in the blood. Common symptoms include itching, weight loss, altered mental status, and fluid retention. Rationale 5: Insomnia. Uremia is a classic sign of renal failure in which urea and other nitrogen-containing waste products are found in the blood. Common symptoms include itching, weight loss, altered mental status, and fluid retention. Fatigue rather than insomnia is another symptom. Global Rationale: Uremia is a classic sign of renal failure in which urea and other nitrogen-containing waste products are found in the blood. Common symptoms include itching, weight loss, altered mental status, and fluid retention. Fatigue rather than insomnia is another symptom. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.6: Differentiate normal from abnormal findings in physical assessment of the urinary system.

Question 11 Type: MCSA A client has a spinal cord injury with paralysis at C5 level. When completing discharge teaching, which of the following client statements would require further teaching? 1. “I need to perform self-catheterization three times daily.” 2. “I know I cannot look to see if my bladder is full.” 3. “I need to avoid bladder distention.” 4. “I’ll drink adequate amounts of liquids.” Correct Answer: 1 Rationale 1: “I need to perform self-catheterization three times daily,” would indicate the client needs further teaching since emptying the bladder only 3 times in 24 hours is insufficient. Dysreflexia occurs in clients with spinal cord injuries at level T7 or higher. Bladder distention causes a sympathetic response that can trigger a potentially life-threatening hypertensive crisis. It would be crucial for the client with this type of injury to avoid bladder distention by performing self-catheterization before this happens, most likely every 3 to 4 hrs. Rationale 2: “I know I cannot look to see if my bladder is full,” would indicate the client understands his condition and care. By the time the client can see his abdomen expand or have a sense of bladder fullness—if able to have this sensation—the bladder would be overdistended and dysreflexia could occur. Dysreflexia occurs in clients with spinal cord injuries at level T7 or higher. Bladder distention causes a sympathetic response that can trigger a potentially life-threatening hypertensive crisis. It would be crucial for the client with this type of injury to avoid bladder distention. Rationale 3: “I need to avoid bladder distention,” indicates that the client understands his condition and care. Bladder distention can lead to dysreflexia. Dysreflexia occurs in clients with spinal cord injuries at level T7 or higher. Bladder distention causes a sympathetic response that can trigger a potentially life-threatening hypertensive crisis. Rationale 4: “I’ll drink adequate amounts of liquids,” indicates that the client understands his condition and care. Adequate fluid intake is appropriate for the urinary system to function properly and to maintain homeostasis. Global Rationale: Dysreflexia occurs in clients with spinal cord injuries at level T7 or higher. Bladder distention causes a sympathetic response that can trigger a potentially life-threatening hypertensive crisis. It would be crucial for the client with this type of injury to avoid bladder distention by performing self-catheterization before this happens, most likely every 3 to 4 hrs. By the time the client can see his abdomen expand or have a sense of bladder fullness—if able to have this sensation—it may be too late to avoid dysreflexia. Liquids are important in maintaining the urinary system. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20.9: Apply critical thinking in selected simulations related to physical assessment of the urinary system. Question 12 Type: HOTSPOT The nurse is performing a urinary system assessment and wishes to percuss at the right costovertebral angle. Draw an arrow to the spot where the nurse would find this.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The nurse places the right hand flat over the right costovertebral angle, then thumps the back of the right hand with the ulnar surface of the left fist. Pain or discomfort during and after blunt percussion suggests kidney disease. The client should feel no pain or tenderness with pressure or percussion, but findings must be correlated with other assessment data. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.2: Identify landmarks that guide assessment of the urinary system. Question 13 Type: MCSA The nurse is interviewing the parents of a toddler who state they are concerned about the child’s bedwetting. The best response for the nurse in this situation is which of the following? 1. “"Be sure to limit the child’s fluid intake during the evening.” 2. “Don’t worry; all children wet the bed.” 3. “We’ll obtain a specimen to check for a urinary tract infection.” 4. “This problem will be gone at the age of 4.” Correct Answer: 1 Rationale 1: Most bedwetting ceases by the age of 4 or 5. If the parents are concerned enough to bring the problem to your attention, they’re interested in suggestions for help. Limiting fluid intake in the evening or waking the child to void are methods to address the problem. Rationale 2: “Don’t worry; all children wet the bed,” dismisses the parents concerns is not a therapeutic response. Rationale 3: Obtaining a specimen to rule out a urinary tract infection may be appropriate but would have to be correlated with other symptomatology and assessment findings; therefore, this is not the best response by the nurse. Rationale 4: While most bedwetting ceases by the age of 4 or 5, stating that “This problem will be gone at the age of 4” is not a therapeutic response since the nurse cannot make this guarantee. Global Rationale: Most bedwetting ceases by the age of 4 or 5. If the parents are concerned enough to bring the problem to your attention, they’re interested in suggestions for help. Limiting fluid intake before bedtime or waking the child to void are methods to address the problem. Dismissing their concerns is not therapeutic. Ruling out a urinary tract infection may be appropriate but would have to be correlated with other symptomatology and assessment findings. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 14 Type: MCSA

During the assessment of a client with multiple injuries, the nurse notices a large hematoma located at the left costovertebral angle. The nurse should suspect injury to which of the following organs? 1. Kidney 2. Ribs 3. Intestines 4. Bladder Correct Answer: 1 Rationale 1: The two kidneys are located outside the peritoneal cavity and on either side of the vertebral column at the levels of T12 through L3, also termed the costovertebral angle; therefore, a hematoma in this area should alert the nurse to the possibility of injury to the kidney. Rationale 2: The ribs encompass a larger area than just the costovertebral angle. Rationale 3: The intestine does not lie at the costovertebral angle. Rationale 4: The bladder does not lie at the costovertebral angle. Global Rationale: The two kidneys are located outside the peritoneal cavity and on either side of the vertebral column at the levels of T12 through L3, also termed the costovertebral angle. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.2: Identify landmarks that guide assessment of the urinary system. Question 15 Type: MCSA The nurse is caring for a client admitted with an infection of the ureters. The nurse realizes this infection could include which of the following structures of the kidney? 1. Capsule 2. Cortex 3. Medulla 4. Pelvis Correct Answer: 4

Rationale 1: The renal capsule is the tissue that surrounds the kidney. It is not directly connected to the ureter as the renal pelvis is, so infection would not be as likely to travel from the ureter to the capsule. Rationale 2: The renal cortex is the outer portion of each kidney. The renal cortex is not directly connected to the ureter as the renal pelvis is, so infection would not be as likely to travel from the ureter to the cortex. Rationale 3: The renal medulla is the inner portion of the kidney and is not continuous with the ureter as the renal pelvis is, so infection would not be as likely to travel from the ureter to the medulla. Rationale 4: The renal pelvis is the funnel-shaped superior end of the ureter. Since it is continuous with the ureter, an infection in the ureter could easily travel to the renal pelvis. Global Rationale: Since the renal pelvis is continuous with the ureter at the end of the ureter; therefore, an infection in the ureters could travel to the renal pelvis. The renal capsule, cortex, and medulla are not continuous with the ureters. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.1: Describe the anatomy and physiology of the urinary system; Question 16 Type: MCSA A client’s blood pressure suddenly falls from 120/80 to 90/60. Which of the following is a major role of the kidney in this situation? 1. Increasing hydrostatic pressure 2. Release of renin 3. Increasing glomerular filtration rate 4. Dilation of renal vessels Correct Answer: 2 Rationale 1: Increasing hydrostatic pressure is not a major role of the kidneys in response to a sudden decrease in system blood pressure. Rationale 2: The kidneys produce and release the enzyme renin to assist in regulation of blood pressure. This is achieved by the drop in systemic blood pressure triggering the juxtaglomerular cells to release renin. Renin acts on angiotensinogen to release angiotensin I, which is in turn converted to angiotensin II. Angiotensin II activates vascular smooth muscle throughout the body, causing systemic blood pressure to rise. Rationale 3: Glomerular filtration rate is a test used to check kidney function. It estimates how much blood passes through glomeruli each minute.

Rationale 4: Dilation of renal vessels is not a major role of the kidneys in response to a sudden decrease in system blood pressure. Global Rationale: A drop in systemic blood pressure often triggers the juxtaglomerular cells to release renin. Renin acts on angiotensinogen to release angiotensin I, which is in turn converted to angiotensin II. Angiotensin II activates vascular smooth muscle throughout the body, causing systemic blood pressure to rise. Thus, the reninangiotensin mechanism is a factor in renal autoregulation, even though its main purpose is the control of systemic blood pressure. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 20.1: Describe the anatomy and physiology of the urinary system. Question 17 Type: MCMA The nurse is preparing an educational session on kidney health for a church group. Which of the following would the nurse include as the leading cause of end-stage renal disease? Standard Text: Select all that apply. 1. Diabetes mellitus 2. Alcoholism 3. Hypertension 4. Cardiovascular disease 5. Obesity Correct Answer: 1,3 Rationale 1: Diabetes mellitus. Diabetes mellitus affects the blood vessels of the renal system and is a leading cause of end-stage renal disease. Rationale 2: Alcoholism. Alcoholism is not a leading cause of end-stage renal disease. Rationale 3: Hypertension. Hypertension affects the blood vessels of the renal system and is a leading cause of end-stage renal disease. Rationale 4: Cardiovascular disease. Cardiovascular disease is not a leading cause of end-stage renal disease. Rationale 5: Obesity. Obesity is not a leading cause of end-stage renal disease.

Global Rationale: Diabetes and hypertension increase the risk for end-stage renal disease. Alcoholism, cardiovascular disease, and obesity are not leading causes of end-stage renal disease. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.8: Discuss the objectives of Healthy 2020 as they relate to the urinary system. Question 18 Type: MCSA The nurse is preparing an educational session on kidney health for a church group. Which of the following groups would the nurse note to have the highest incidence of end-stage renal disease? 1. Mexicans 2. Asians 3. African Americans 4. American Indians Correct Answer: 3 Rationale 1: The Mexican population has a high rate of renal disease, but not as high as African Americans. Rationale 2: The Asian population has a high rate of renal disease, but not as high as African Americans. Rationale 3: African Americans have the highest rate of renal disease among culture and ethnic groups. Rationale 4: American Indians have a high rate of renal disease, but not as high as African Americans. Global Rationale: Although all the listed populations have higher rates of renal disease than whites, the occurrence of end-stage renal disease is highest in the African American group. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 19 Type: MCSA The nurse is obtaining a medication history on a newly admitted client with renal dysfunction. Which of the following medication classifications would the nurse note as significant for this client?

1. Antihypertensives 2. Analgesics 3. Antihyperlipidemics 4. Diuretics Correct Answer: 2 Rationale 1: Antihypertensive medications have not been found to be directly linked to renal disease. Rationale 2: The prolonged use of analgesics, especially over-the-counter drugs like ibuprofen and acetaminophen, has been linked with renal disease. Rationale 3: Antihyperlipidemic medications have not been found to be directly linked to renal disease. Rationale 4: Diuretic medications have not been found to be directly linked to renal disease. Global Rationale: The prolonged use of analgesics, especially over-the-counter drugs like ibuprofen and acetaminophen, has been linked with renal disease. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.3: Develop questions to be used when completing the focused interview. Question 20 Type: MCSA A client experienced blood loss from surgery. What is the impact of this blood loss on the kidney’s functioning? 1. Altered filtering ability of the kidneys 2. No impact on kidney function 3. Absorption of calcium and phosphate decreased 4. Stimulation of the kidneys to produce erythropoietin Correct Answer: 4 Rationale 1: The kidneys would produce the hormone erythropoietin in response to a client experiencing blood loss during surgery. Erythropoietin then stimulates the bone marrow to produce red blood cells. The filtering ability of the kidneys would not be directly affected by blood lost during surgery.

Rationale 2: Blood loss does cause an impact on the kidneys. The kidneys would produce the hormone erythropoietin in response to a client experiencing blood loss during surgery. Erythropoietin then stimulates the bone marrow to produce red blood cells. Rationale 3: The kidneys would produce the hormone erythropoietin in response to a client experiencing blood loss during surgery. Erythropoietin then stimulates the bone marrow to produce red blood cells. A decrease in the absorption of calcium and phosphate would not occur as a response to the blood loss. Rationale 4: The kidneys would produce the hormone erythropoietin in response to a client experiencing blood loss during surgery. Erythropoietin then stimulates the bone marrow to produce red blood cells. Global Rationale: The kidneys would produce the hormone erythropoietin in response to the blood lost during surgery. Erythropoietin then stimulates the bone marrow to produce red blood cells. Blood loss would not cause altered filtering ability, or decreased absorption of calcium and phosphate from the kidneys. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.1: Describe the anatomy and physiology of the urinary system. Question 21 Type: MCSA The nurse is teaching an adult client who is participating in rehabilitation for bladder retraining. Which of the following amounts of urine would cause the bladder to distend above the symphisis pubis? 1. 100 ml 2. 200 ml 3. 500 ml 4. 700 ml Correct Answer: 4 Rationale 1: 100 ml is not enough urine to cause bladder distention. When more than 500 ml of urine is present, the bladder becomes distended and rises above the symphysis pubis. Rationale 2: 200 ml is not enough urine to cause bladder distention. When more than 500 ml of urine is present, the bladder becomes distended and rises above the symphysis pubis. Rationale 3: Greater than 500 ml of urine in the bladder causes the bladder to become distended and rise above the symphysis pubis. Rationale 4: Since greater than 500 ml of urine in the bladder causes the bladder to become distended and rise above the symphysis pubis, 700 ml would cause bladder distention.

Global Rationale: When amounts larger than 500 ml are present in the adult bladder, it becomes distended and rises above the symphysis pubis. 700 ml is the only amount listed that is above 500 ml. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.2: Identify landmarks that guide assessment of the urinary system. Question 22 Type: MCSA The nurse is measuring the urinary output for a client and notes 450 ml of urine. The nurse would determine that this urine amounts is: 1. Decreased from normal. 2. Concentrated from what is normal. 3. Increased from normal. 4. Normal amount. Correct Answer: 4 Rationale 1: While the size of the bladder varies slightly in adults, the adult bladder typically holds approximately 300 to 500 ml of urine; therefore, 450 ml would not be considered decreased from normal amounts. Rationale 2: Concentrated urine refers to the degree of dilution of the urine rather than the amount. Rationale 3: While the size of the bladder varies slightly in adults, the adult bladder typically holds approximately 300 to 500 ml of urine; therefore, 450 ml would not be considered increased from normal amounts. Rationale 4: The adult bladder typically holds approximately 300 to 500 ml of urine, so 450 ml would be considered within the normal range of urine. Global Rationale: The size of the bladder varies with the amount of urine it contains. In healthy adults, the bladder holds about 300 to 500 ml of urine; therefore, 450 ml would be considered a normal amount of urine. Concentration of the urine refers to the degree of dilution of the urine rather than the amount. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 20.6: Differentiate normal from abnormal findings in physical assessment of the urinary system.

Question 23 Type: MCSA The nurse is preparing to catheterize a client after the client has just independently voided. The purpose of this catheterization would be to: 1. serve as a urine output baseline. 2. support the diagnosis of kidney stones. 3. evaluate the ability of the client to empty the bladder. 4. evaluate renal function. Correct Answer: 3 Rationale 1: Catheterizing a client following independent voiding is a post-void residual urine test. This test is performed to evaluate the bladder’s ability to empty urine. Both the voided and catheterized amount should be recorded. This procedure would not indicate the client’s urine output baseline. Rationale 2: Catheterizing a client following independent voiding is a post-void residual urine test. This test is performed to evaluate the bladder’s ability to empty urine. Both the voided and catheterized amount should be recorded. This procedure would not be used to evaluate the client for kidney stones. Rationale 3: Catheterizing a client following independent voiding is a post-void residual urine test. This test is performed to evaluate the bladder’s ability to empty urine. Both the voided and catheterized amount should be recorded. Rationale 4: Catheterizing a client following independent voiding is a post-void residual urine test. This test is performed to evaluate the bladder’s ability to empty urine. Both the voided and catheterized amount should be recorded. This procedure would not be performed to evaluate renal function. Renal function would be evaluated through lab tests such as BUN and creatinine levels. Global Rationale: This procedure is a post-voiding residual urine test. This test is performed to evaluate the bladder’s ability to empty urine. Both the voided and catheterized amount should be recorded. This procedure would not indicate urine output baseline, kidney stones, or renal function. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.4: Explain client preparation for assessment of the urinary system. Question 24 Type: MCSA A client is admitted with possible renal calculi. The client asks, “Are there are any tests that can be performed to show the doctor if there are any kidney stones?” The nurse would be correct in responding:

1. “The intravenous pyelogram will allow the healthcare provider to visualize kidney stones.” 2. “A 24-hour urine specimen will allow the healthcare provider to visualize kidney stones.” 3. “A routine urinalysis will allow the healthcare provider to visualize kidney stones.” 4. “A kidney biopsy will allow the healthcare provider to visualize kidney stones.” Correct Answer: 1 Rationale 1: The intravenous pyelogram is a radiologic examination that allows visualization of renal calculi in the kidneys, ureters, and bladder. Rationale 2: A 24-hour urine specimen would not aid in visualization of renal calculi. The 24-hour urine specimen could be used to evaluate such things as creatinine levels in the urine. Rationale 3: A routine urinalysis would not aid in visualization of renal calculi. The routine urinalysis exams such things as specific gravity, pH, presence of bacteria, and several other factors. Rationale 4: A kidney biopsy would not aid in visualization of renal calculi. A kidney biopsy would be performed to determine the presence of kidney diseases such as cancer. Global Rationale: The intravenous pyelogram is a radiologic examination that allows visualization of renal calculi in the kidneys, ureters, and bladder. The other exams listed would not aid in visualization of renal calculi. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.4: Explain client preparation for assessment of the urinary system. Question 25 Type: MCMA A teenage girl visits the school nurse to ask why she is getting frequent urinary tract infections. Which of the following questions should the nurse ask the client during this visit? Standard Text: Select all that apply. 1. “Have you been eating foods that have high acidity?” 2. “Do you drink a lot of milk?” 3. “Do you take bubble baths frequently?” 4. “What direction do you wipe after a bowel movement?” 5. “Do you have a family history of urinary tract infections?”

Correct Answer: 3,4 Rationale 1: “Have you been eating foods that have high acidity?” is not an appropriate response since foods high in acidity do not cause urinary tract infections. Rationale 2: “Do you drink a lot of milk?” is not an appropriate response since the intake of milk does not cause urinary tract infections. Rationale 3: “Do you take bubble baths frequently?” is an appropriate response. Frequent bubble baths have been found to cause urinary tract infections due to irritation and introduction of bacteria. Rationale 4: “What direction do you wipe after a bowel movement?” is an appropriate response. Females should wipe the peri-anal/genital area from front to back. E-coli is the most common microorganism responsible for urinary tract infections and can easily be dragged into the urethral orifice by wiping from the anus to the urethra after defecation. Females do have a shorter urethra compared to males and are more susceptible to urinary tract infections for this reason. Rationale 5: “Do you have a family history of urinary tract infections?” is not an appropriate response. A family history of urinary tract infections does increase an individual’s risk for developing urinary tract infections. Global Rationale: Females should wipe the peri-anal/genital area from front to back. E-coli is the most common microorganism responsible for urinary tract infections and can easily be dragged into the urethral orifice by wiping from the anus to the urethra after defecation. Females do have a shorter urethra compared to males and are more susceptible to urinary tract infections for this reason. Taking frequent bubble baths has also been found to lead to urinary tract infections in females. Eating foods high in acidity, drinking large amounts of milk, and family members with urinary tract infections does not increase the risk for urinary tract infections. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 26 Type: MCSA A postpartum client with a difficult vaginal delivery 36 hours ago tells the nurse that she has not felt the need to void much since delivery. The nurse would respond with which of the following statements? 1. “The inside of your bladder is most likely swollen, which makes you feel like you don’t have to urinate.” 2. “You must be overdoing it with your activity level so soon after delivery.” 3. “I will need to catheterize you.” 4. “Your uterus must not be enlarged any longer.”

Correct Answer: 1 Rationale 1: “The inside of your bladder is most likely swollen, which makes you feel like you don’t have to urinate,” is an accurate response since during childbirth, the bladder mucosa may become edematous, causing decreased sensation and potential overdistention of the bladder. Bladder distention increases susceptibility to infection and other postpartum problems. Rationale 2: “You must be overdoing it with your activity level so soon after delivery,” would not be an accurate response. An increase in activity level would not cause the client to have a lack of sensation to void. Rationale 3: Immediate catheterization would not be necessary as long as the client is able to void in adequate amounts. Rationale 4: “Your uterus must not be enlarged any longer,” is not an accurate response since a decrease in uterine size would not cause the client to have a decreased sensation for the need to void. Global Rationale: During childbirth, the bladder mucosa may become edematous, causing decreased sensation and potential overdistention of the bladder, which increases susceptibility to infection and other postpartum problems. An increase in activity level would not cause the client to have a lack of sensation to void. Immediate catheterization would not be necessary as long as the client is able to void in adequate amounts. A decrease in uterine size would not cause the client to have a decreased sensation for the need to void. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 27 Type: MCSA During the assessment of a client’s urinary system, the nurse learns that the client has painful urination. The nurse would document this finding as: 1. Dysuria. 2. Hematuria. 3. Oliguria. 4. Polyuria. Correct Answer: 1 Rationale 1: Dysuria is the term used for painful urination so the nurse would be correct in documenting this finding.

Rationale 2: Hematuria is the term used for blood in the urine; therefore, this term would not be used to describe painful urination. Rationale 3: Oliguria is the term used for decreased urine output; therefore, this term would not be used to describe painful urination. Rationale 4: Polyuria is the term used for increased urine output; therefore, this term would not be used to describe painful urination. Global Rationale: Painful urination is termed dysuria. Hematuria is blood in the urine; oliguria is decreased urine output; polyuria is increased urine output. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.6: Differentiate normal from abnormal findings in physical assessment of the urinary system. Question 28 Type: MCSA During the assessment of a client’s renal system, the nurse is unable to palpate the kidneys. This nurse would consider this finding as: 1. An indication of an inflammatory condition of the kidneys. 2. A sign of acute or chronic renal disease. 3. Normal. 4. A sign of polycystic kidney disease. Correct Answer: 3 Rationale 1: The kidneys are not normally palpable unless they are enlarged. Enlargement usually occurs as a result of a disease process affecting the kidneys. Rationale 2: The kidneys are not normally palpable unless they are enlarged. Enlargement usually occurs as a result of a disease process affecting the kidneys. Acute or chronic renal failure would be diagnosed through other methods, such as diagnostic and laboratory testing. Rationale 3: The nurse is correct in considering it to be normal to be unable to palpate the kidneys. Enlargement usually occurs as a result of a disease process affecting the kidneys. Rationale 4: The kidneys are not normally palpable unless they are enlarged. Enlargement usually occurs as a result of a disease process affecting the kidneys, such as polycystic kidney disease.

Global Rationale: The kidneys are normally not palpable; therefore, the other options are not indicated by being unable to palpate the kidneys. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.6: Differentiate normal from abnormal findings in physical assessment of the urinary system. Question 29 Type: MCSA The nurse is able to percuss a dull tone over a client’s bladder after the client has voided 300 ml of urine. The nurse would conclude which of the following is most likely the cause of this finding? 1. This is a normal finding 2. Possible urinary tract infection 3. This is a sign of prostate enlargement 4. Probable urinary retention Correct Answer: 4 Rationale 1: This is not a normal finding as there should be little to no urine remaining in the bladder following urination. A dull percussion tone over the bladder of a client who has just urinated indicates urinary retention, and further evaluation is necessary. Rationale 2: Little to no urine should remain in the bladder following urination. A dull percussion tone over the bladder of a client who has just urinated indicates urinary retention, and further evaluation is necessary. Urinary retention can lead to urinary tract infections, but this could not be concluded without additional testing. Rationale 3: Little to no urine should remain in the bladder following urination. A dull percussion tone over the bladder of a client who has just urinated indicates urinary retention, and further evaluation is necessary Prostate enlargement usually affects the client’s ability to start the urine flow and maintain a strong urine flow, so urinary retention would not indicate this condition. Rationale 4: Little to no urine should remain in the bladder following urination. A dull percussion tone over the bladder of a client who has just urinated indicates urinary retention, and further evaluation is necessary. Global Rationale: This is not a normal finding as there should be little to no urine remaining in the bladder following urination. A dull percussion tone over the bladder of a client who has just urinated indicates urinary retention, and further evaluation is necessary. Urinary retention can lead to urinary tract infections, but this could not be concluded without additional testing. Prostate enlargement usually affects the client’s ability to start the urine flow and maintain a strong urine flow, so urinary retention would not indicate this condition.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.6: Differentiate normal from abnormal findings in physical assessment of the urinary system. Question 30 Type: MCSA An elderly female comes into the clinic to be seen for urinary incontinence. The nurse recognizes that this problem: 1. Is common with aging. 2. Often occurs as a secondary problem. 3. Indicates decreased renal blood flow. 4. Is related to medications. Correct Answer: 2 Rationale 1: Aging does not necessarily cause urinary incontinence. Rationale 2: Urinary incontinence is often secondary to another problem such as urinary tract infections or difficulty getting to the bathroom due to mobility issues. Rationale 3: Urinary incontinence is not related to renal blood flow. Renal blood flow may affect the amount of urine produced by the kidneys. Rationale 4: Medications do not typically cause urinary incontinence; rather, medications may be given to treat urinary some types of urinary incontinence. Global Rationale: Urinary incontinence is not a normal sign of aging and therefore should be evaluated further for this client. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.6: Differentiate normal from abnormal findings in physical assessment of the urinary system. Question 31 Type: MCMA

The nurse is preparing a client for assessment of the urinary system. The nurse would include which of the following assessment techniques in this examination? Standard Text: Select all that apply. 1. Inspection 2. Palpation 3. Percussion 4. Auscultation 5. Client interview Correct Answer: 1,2,3,4,5 Rationale 1: Inspection. The nurse uses each of the listed techniques in assessment of the urinary system. Inspection would be used for assessing factors such as the appearance of the urine. Rationale 2: Palpation. The nurse uses each of the listed techniques in assessment of the urinary system. Palpation would include assessing factors such as bladder distention; percussion is used to determine factors such as the presence of urine in the bladder. Rationale 3: Percussion. The nurse uses each of the listed techniques in assessment of the urinary system. Inspection would be used for assessing factors such as the appearance of the urine. Percussion is used to determine factors such as the presence of urine in the bladder. Rationale 4: Auscultation. The nurse uses each of the listed techniques in assessment of the urinary system. Auscultation would be used in assessment of the renal arteries. Rationale 5: Client interview. The nurse uses each of the listed techniques in assessment of the urinary system. The client interview provides important information regarding the overall urinary history of the client. Global Rationale: The nurse uses each of the listed techniques in assessment of the urinary system. Inspection would be used for assessing factors such as the appearance of the urine; palpation would include assessing factors such as bladder distention; percussion is used to determine factors such as the presence of urine in the bladder; auscultation would be used in assessment of the renal arteries; and the client interview provides important information regarding the overall urinary history of the client. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4: Explain client preparation for assessment of the urinary system. Question 32 Type: MCSA

The nurse is assessing a client after a motor vehicle accident and notes the presence of ecchymosis in the left flank area. The nurse would interpret this finding as which of the following? 1. Positive Grey Turner’s sign 2. Costovertebral angle tenderness 3. Possible clotting dysfunction 4. A precursor to hematuria Correct Answer: 1 Rationale 1: The presence of ecchymosis in the flank area is a positive Grey Turner’s sign and must be correlated to signs of trauma such as blunt penetrating wounds or lacerations. Rationale 2: Tenderness in the costovertebral angle is a symptom the client would voice if present; ecchymosis in this area does not necessarily indicate tenderness. The presence of ecchymosis in the flank area is a positive Grey Turner’s sign and must be correlated to signs of trauma such as blunt penetrating wounds or lacerations. Rationale 3: A clotting problem could cause bruising, but bruising in this specific area would be more indicative of a positive Grey Turner’s sign. Rationale 4: Hematuria is not necessarily going to occur as a result of the findings. The presence of ecchymosis in the flank area is a positive Grey Turner’s sign and must be correlated to signs of trauma such as blunt penetrating wounds or lacerations Global Rationale: The presence of ecchymosis in the flank area is a positive Grey Turner’s sign and must be correlated to signs of trauma such as blunt penetrating wounds or lacerations. Tenderness in the costovertebral angle is a symptom the client would voice if present; ecchymosis in this area does not necessarily indicate tenderness. A clotting problem could cause bruising, but bruising in this specific area would be more indicative of a positive Grey Turner’s sign. Hematuria is not necessarily going to occur as a result of the findings. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 20.6: Differentiate normal from abnormal findings in physical assessment of the urinary system. Question 33 Type: MCSA The nurse is interviewing a client who states the presence of urinary incontinence with coughing and sneezing. The nurse would correctly document this type of incontinence as which of the following? 1. Functional

2. Reflex 3. Stress 4. Urge Correct Answer: 3 Rationale 1: This documentation would be incorrect as functional incontinence results when there is an inability to reach the toilet in time. The symptoms reported indicate stress incontinence. Rationale 2: This documentation would be incorrect as reflex incontinence occurs with spinal cord damage. The symptoms reported indicate stress incontinence. Rationale 3: This documentation would be correct. Stress incontinence is involuntary urination occurring with coughing, sneezing, or straining. Stress incontinence and be either partial or complete leakage of urine form the bladder. Rationale 4: This documentation would be incorrect as urge incontinence may be due to excessive intake of fluids, diminished bladder capacity, or urinary tract infection. Global Rationale: Stress incontinence is involuntary urination occurring with coughing, sneezing, or straining. Stress incontinence and be either partial or complete leakage of urine form the bladder. Functional incontinence results when there is an inability to reach the toilet in time; reflex incontinence occurs with spinal cord damage; and urge incontinence may be due to excessive intake of fluids, diminished bladder capacity, or urinary tract infection. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 34 Type: HOTSPOT Draw an arrow to the structure in the kidney that is made up of pyramids and calyces, whose function is to collect urine and transport it into the renal pelvis.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The renal medulla is composed of structures called pyramids and calyces. The pyramids are wedge like structures made up of bundles of urine-collecting tubules. At their apex, the pyramids have papillae that are enclosed by cuplike structures called calyces. The calyces collect urine and transport it into the renal pelvis, which is the funnel-shaped superior end of the ureter. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.1: Describe the anatomy and physiology of the urinary system.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 21 Question 1 Type: MCSA 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. Document the findings as normal. 2. Inform the client that he is no longer fertile. 3. Notify the healthcare provider of the findings. 4. Ask the client about his sexual practices. Correct Answer: 1 Rationale 1: The older adult male begins to demonstrate thinning and graying of the pubic hair. The penis and testicles begin to diminish in size and the scrotum hangs lower. Rationale 2: Sperm production in the middle aged and older man is reduced but there is still adequate sperm production to father children. Rationale 3: The findings are normal and do now warrant notification of the healthcare provider. Rationale 4: The sexual practices of the client are not impacted by the findings. Inquiry into them is not indicated at this time. Global Rationale: According to Tanner’s Maturation Stages in the male, the findings in this situation are appropriate for the elderly male client. Although sperm production does decline during middle age, the presence of viable sperm in the elderly male contradicts infertility. No further subjective information is required by the nurse, and the healthcare provider does not need notification. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive system. Question 2 Type: MCSA During the examination of a male client who has not been circumcised, the nurse is attempts to retract the foreskin of the penis, but skin is very tight and cannot be pulled back. The nurse would correctly anticipate which of the following conditions?

1. Urethral stricture 2. Paraphimosis 3. Urethritis 4. Phimosis Correct Answer: 4 Rationale 1: Urethral strictures would be suspected in the event of voiding problems or a pinpoint size meatus opening was noted not an inability to retract the foreskin over the glans penis. Rationale 2: Paraphimosis is a condition in which the foreskin cannot be moved back over the glans penis once it has been retracted Rationale 3: Urethritis manifests with symptoms including redness and edema around the glans and foreskin, eversion of the urethral mucosa, and drainage. Rationale 4: Phimosis refers to a condition in which the foreskin cannot be moved back over the glans penis. Global Rationale: Phimosis is a condition in which the foreskin is too tight to retract over the glans penis. Paraphimosis is a condition in which the foreskin cannot be moved back over the glans penis once retracted. Urethritis is a condition in which the urethra is infected or inflamed. Signs of urethritis include redness and edema around the glans and foreskin, eversion of urethral mucosa, and drainage. A urethral stricture is suspected if the urinary meatus is pinpoint size. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive system. Question 3 Type: MCSA The nurse is interviewing a male client who states “I feel like I have a bag of worms in my scrotum.” The nurse would correctly suspect which of the following conditions? 1. Orchitis 2. Varicocele 3. Epididymitis 4. Hernia Correct Answer: 2

Rationale 1: Orchitis refers to a swelling and inflammation of the testicles. Rationale 2: A varicocele is a distention of the spermatic cord and may be described as a “bag of worms.” Rationale 3: Epididymitis is an inflammatory condition of the epididymis. Rationale 4: An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal, which indicates a protrusion of the intestine into the groin region. Global Rationale: Swelling or inflammation of the testicles is referred to as orchitis. A varicocele is a distention of the spermatic cord and often is described as “a bag of worms.” Epididymitis is an inflammatory condition of the epididymis. An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal, which indicates a protrusion of the intestine into the groin region. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive system. Question 4 Type: MCMA When caring for a male client scheduled for a prostatectomy due to cancer, the nurse would expect which of the following assessment findings to be present? Standard Text: Select all that apply. 1. Enlargement of the scrotal sac 2. Pyuria 3. Increase in prostatic specific antigen (PSA) 4. Dribbling of urine 5. Difficulty in initiating urine stream Correct Answer: 3,4,5 Rationale 1: Enlargement of the scrotal sac. The scrotal sac will not be enlarged with a diagnosis for prostate cancer. Scrotal sac enlargement may be noted in the presence of inflammation of the testicles or the epididymis. Rationale 2: Pyruia. Pyruia refers to pus in the urine. Pus in the urine is not consistent with the presence of prostate cancer. Rationale 3: Increase in prostatic specific antigen (PSA). Low levels of prostatic specific antigen are present in normal, healthy men. Laboratory values for the PSA will be elevated in the presence of prostate cancer.

Rationale 4: Dribbling of urine. The dribbling of urine may be seen with prostate cancer. Dribbling will occur in the presence of prostate enlargement. Rationale 5: Difficulty in initiating urine stream. Prostate enlargement as seen in malignant conditions may result in the client experiencing difficulty in initiating the urine stream. Global Rationale: The scrotal sac of the client diagnosed with prostate cancer would not be enlarged. The prostate is located on each side of the male urethra just below the bladder. It is not anatomically near the scrotal sac. Pyruia refers to pus in the urine. Pus in the urine is not consistent with a diagnosis of prostate cancer. Low levels of prostatic specific antigen (PAS) are present in normal, healthy men. PSA levels are used to assess for the presence of prostate cancer. Laboratory values for the PSA will be elevated in the presence of prostate cancer. Conditions of the prostate gland may result in urinary changes. The dribbling of urine may be seen with prostate cancer. Dribbling or difficulty starting the urine stream may be seen in the presence of prostate enlargement. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive system. Question 5 Type: MCSA While performing prostate palpation, the nurse notes that the client expresses severe tenderness and discomfort during the procedure. The nurse should suspect which of the following conditions in the client? 1. Prostate cancer 2. Prostatitis 3. Enlargement of the prostate 4. Urinary tract infection Correct Answer: 2 Rationale 1: The presence of extreme hardness or nodules is characteristic of prostate cancer. Rationale 2: The prostate should feel smooth, firm, or rubbery, and extend no larger than 1 centimeter into the rectal area. This exam should not cause tenderness, which is an indication of inflammation. Rationale 3: Enlargement of the prostate will cause urinary tract symptoms such as difficulty in starting a stream, or dribbling of urine. Rationale 4: Urinary tract infections will cause painful and frequent urination. Global Rationale: Upon examination, the prostate should feel smooth, firm, or rubbery, and extend no larger than 1 centimeter into the rectal area. This exam should not cause tenderness, which is an indication of inflammation.

The presence of extreme hardness or nodules is characteristic of prostate cancer. Enlargement of the prostate will cause urinary tract symptoms such as difficulty in starting a stream, or dribbling of urine. Urinary tract infections will cause painful and frequent urination. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive system. Question 6 Type: HOTSPOT The nurse is providing education to a client who has been experiencing symptoms consistent with BPH. The nurse presents a diagram the client to illustrate the location of the prostate. Mark with an “X” the correct location of the prostate gland.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The lobes of the prostate gland are located on each side of the male urethra. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive system. Question 7 Type: HOTSPOT The nurse is caring for a client who has hypospadias . Mark the figure provided to illustrate the location of the phenomena.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : Hypospadias is a condition in which the urinary meatus opens on the underside of the penis. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive system. Question 8 Type: MCSA

A couple seeking infertility treatments has just received the results of a semen analysis, which shows a diminished sperm count. The nurse would ask which of the following questions to the male in this scenario? 1. “How often do you masturbate?” 2. “Do you smoke?” 3. “How old is your present house?” 4. “Do you still want to have children?” Correct Answer: 3 Rationale 1: Masturbation does not influence sperm count and the ability to father children. Rationale 2: Tobacco use does not impact sperm count and the ability to father children. Rationale 3: The age of the home may be influencing the sperm count. Lead paint may be present in older homes built before 1979. Lead exposure may result in reduced libido, diminished sperm count and abnormal sperm motility. Rationale 4: The responsibility of the nurse is to assess for related causes, not to assess the desire to father children. Global Rationale: Males exposed to lead may experience decreased libido, diminished sperm count, and abnormal sperm motility. Lead may be present is homes built before 1979. Masturbation and tobacco use do not influence sperm count and motility. The responsibility of the nurse is to assess for related causes, not to assess the desire to father children. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.2: Develop questions to be used when completing the focused interview. Question 9 Type: MCSA During the focused interview, a male client describes his erection and ejaculate in terms that are less than professional. The nurse would correctly do which of the following? 1. Ask the client to refrain from using the terms. 2. Ask the client to define the terms. 3. Document the client’s responses in the terms used. 4. Find another nurse to complete the assessment.

Correct Answer: 3 Rationale 1: Men may be embarrassed to discuss health problems or concerns involving their reproductive organs. During the interview use words that the man can understand, and do not be embarrassed or offended by the words he uses. Rationale 2: Asking the client to define terms may promote a sense of inferiority. Men may be embarrassed to discuss health problems or concerns involving their reproductive organs; it is important for the nurse to ask questions in a non-threatening, matter-of-fact manner. Rationale 3: The words and responses of the client will need to be documented. They provide the framework of the subjective data from the assessment. Rationale 4: Asking another nurse to complete the interview reduces the quality and continuity of care and is inappropriate. Global Rationale: During the interview use words that the man can understand, and do not be embarrassed or offended by the words he uses. Asking the client to define terms may promote a sense of inferiority. Men may be embarrassed to discuss health problems or concerns involving their reproductive organs; it is important for the nurse to ask questions in a nonthreatening, matter-of-fact manner. Consider the psychologic, social, and cultural factors that affect sexuality and sexual activity. The words and responses of the client will need to be documented. Asking another nurse to complete the interview reduces the quality and continuity of care and is inappropriate. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.2: Develop questions to be used when completing the focused interview. Question 10 Type: MCSA 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 perform this exam monthly.” 3. “I should be in a warm room or the shower to perform this exam.” 4. “I should apply gentle pressure to each testicle to feel the area.” Correct Answer: 1 Rationale 1: The contour of the testicles should be firm and smooth. Rationale 2: The testicular self-examination should be performed monthly beginning in adolescence.

Rationale 3: The most opportune time to perform the testicular self-examination is in the shower or bath. Heat and steam will warm the hands and will help their movement over the skin surface. Rationale 4: The correct technique utilizes a gentle pressure over the surface of the skin. Global Rationale: Testicular self-exam should be performed monthly beginning in adolescence. The scrotum will descend in a warm environment such as the bath or shower, allowing adequate palpation. Gentle pressure should be applied to locate the testicle and epididymis, but these areas are normally soft, without lumps or hardness. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 21.3: Describe techniques required for assessment of the male reproductive system. Question 11 Type: MCMA The student nurse is preparing to examine the male reproductive system of a client. Prior To starting the examination the student nurse explains to the supervising nurse the techniques that will be used. Plans to use which of the following indicates the need for further instruction? Standard Text: Select all that apply. 1. Inspection 2. Palpation 3. Percussion 4. Auscultation 5. Aspiration Correct Answer: 3,4,5 Rationale 1: Inspection. The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. Rationale 2: Palpation. The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. Rationale 3: Percussion. The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. Percussion is used to assess the chest and abdomen. Rationale 4: Auscultation. The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. Auscultation is used to assess the gastrointestinal, cardiovascular, and respiratory systems.

Rationale 5: Aspiration. The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. Aspiration may be used to obtain a specimen. Global Rationale: Examination of the male reproductive system will utilize the techniques of inspection and palpation. The external genitalia will be inspected as the onset of the examination. Palpation will be used to assess the organs. Percussion is utilized in the assessment of the gastrointestinal system. Auscultation is used to assess the gastrointestinal, cardiac, and respiratory systems. Aspiration is a technique used to obtain a specimen. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.3: Describe techniques required for assessment of the male reproductive system. Question 12 Type: MCMA The nurse is preparing to examine a male client’s reproductive organs. Which of the following steps should the nurse do in preparation for this examination? Standard Text: Select all that apply. 1. Secure a private examination room. 2. Use clean hands for the examination. 3. Ask the client to lie down on the exam table. 4. Ask the client to empty his bladder. 5. Make sure the room’s temperature is cool and comfortable. Correct Answer: 1,2,4,5 Rationale 1: Secure a private examination room. A private room is indicated to perform a physical examination. Rationale 2: Use clean hands for the examination. The examiner must have clean hands to perform the exam. This will reduce the transmission of infections. Rationale 3: Ask the client to lie down flat on the exam table. The examination may be performed with the client sitting or standing. The client does not need to lie flat. Rationale 4: Ask the client to empty his bladder. Emptying the bladder will reduce discomfort during palpation portions of the exam. In addition, a full bladder may impede the examination. Rationale 5: Make sure the room’s temperature is cool and comfortable. The examination room must be comfortable for the client.

Global Rationale: Ensure that the examining room is warm and private. The examiner will need to wash hands and put on gloves before beginning the examination. The gloves will need to be worn during the examination. Ask the client to empty his bladder, remove his clothing, and put on a gown or drape. The assessment may be done with the client sitting or standing. There is no need for the client to lie flat. Expose only those body parts being examined to preserve modesty. It is necessary for the client to be comfortable. The temperature should be regulated accordingly. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.3: Describe techniques required for assessment of the male reproductive system. Question 13 Type: MCSA During the examination of a male client’s scrotum the nurse detects a hardened area in the right side of the scrotal sac. The nurse would correctly choose which of the following actions to complete first? 1. Ask the client about voiding patterns. 2. Notify the healthcare provider of this finding. 3. Use a light to perform transillumination. 4. Ask the client about sexual practices. Correct Answer: 3 Rationale 1: Voiding patterns are not related to the findings of the examination. Rationale 2: Abnormalities noted on the assessment will need to be reported to the healthcare provider but first, the nurse must obtain additional supporting information to include in the report. Rationale 3: Transillumination is indicated to obtain further information. Rationale 4: The client’s sexual practices do not have direct bearing on the findings. Global Rationale: The scrotum contains the testes and the epididymis, which should not feel hard upon palpation. Areas suggesting abnormalities may be detected using transillumination, or the use of light to examine the scrotum. Upon transillumination, light should shine through the scrotum with a red glow, with the testes showing up as oval structures. Abnormal areas, such as masses, will not show penetration of the light. The client’s voiding patterns or sexual practices are not relevant to this situation, and the nurse requires additional information prior to notification of the healthcare provider. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.3: Describe techniques required for assessment of the male reproductive system. Question 14 Type: HOTSPOT A client has presented for a physical examination. During the examination the nurse palpates to assess the right inguinal region.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The “X” should be placed on the right side at the diagram just below the hair line where the thigh and the scrotum meet. Global Rationale: Cognitive Level: Understanding

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3: Describe techniques required for assessment of the male reproductive system. Question 15 Type: MCSA The nurse is examining a male client and notes small clusters of vesicular lesions on the glans penis. The client states the areas are painful and that often are reddened. The nurse would suspect which of the following? 1. Carcinoma 2. Genital warts 3. Syphilis 4. Genital herpes Correct Answer: 4 Rationale 1: Carcinoma lesions are nodular or ulcerative. Rationale 2: Genital warts present as soft fleshy growths. Rationale 3: Syphilis presents as nonpainful ulcers called chancres. Rationale 4: Genital herpes presents as painful ulcerations. Global Rationale: Genital herpes lesions present as painful ulcerations. Carcinoma lesions are nodular or ulcerative. Genital warts are soft, painless, fleshy growths. Syphilis produces nonpainful ulcers called chancres. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21.4: Differentiate normal from abnormal findings in physical assessment. Question 16 Type: MCSA The nurse is assessing a male infant and notes only one testis. The mother asks what effect this will have on the child. Which of the following would be a correct response by the nurse? 1. “There will be a need for your child to have hormone replacement therapy.” 2. “He will be unable to father children.”

3. “He will do fine and have no problems.” 4. “There will be a normal level of sperm production.” Correct Answer: 1 Rationale 1: The testes produce sperm and testosterone. With one testis, there will be a reduction in produced testosterone requiring hormone replacement therapy. Rationale 2: The exiting testis will produce sperm, which will allow for him to reproduce. Rationale 3: There are implications of the condition. This is a broad and potentially misleading statement. Rationale 4: The testes produce sperm and testosterone. With one testis, there will be a reduction in produced testosterone Global Rationale: The testes produce sperm and testosterone. With one testis, there will be a reduction in produced testosterone and sperm. The client will need to have hormone replacement therapy. Sterility should not be a problem. Expressing that the client will be fine is a broad and potentially misleading statement. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.4: Differentiate normal from abnormal findings in physical assessment. Question 17 Type: MCSA During the examination of a male client, the nurse detects a bulge in the right inguinal area as the client is bearing down. The nurse would correctly interpret this finding as which of the following conditions? 1. Varicocele 2. Prostatitis 3. Orchitis 4. Hernia Correct Answer: 4 Rationale 1: The varicocele is a distention of the spermatic cord. It feels most like a “bag of worms” rather than a mass. Rationale 2: Examination of the prostate gland is performed via the rectum, rather than the inguinal area.

Rationale 3: Orchitis refers to an inflammation in the testicular region. This would present as a pain and swelling in the scrotal region. Rationale 4: An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal, which indicates a protrusion of the intestine into the groin region. Global Rationale: An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal, which indicates a protrusion of the intestine into the groin region. A varicocele is a distention of the spermatic cord and feels like “a bag of worms” rather than a mass. Examination of the prostate gland is performed via the rectum, rather than the inguinal area. Orchitis refers to an inflammation of the testicles. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21.4: Differentiate normal from abnormal findings in physical assessment. Question 18 Type: MCSA The nurse is examining a male client’s genitalia and notices the scrotum is asymmetric. The left side hangs lower than the right side. The nurse would correctly choose which of the following actions? 1. Reassess after increasing the temperature in the room. 2. Report the finding to the healthcare provider. 3. Consider this a normal finding and proceed with palpation of the scrotum. 4. Ask if the client if has noticed this before. Correct Answer: 3 Rationale 1: Elevation in temperatures will facilitate the scrotum’s dropping away from the body. It will not correct symmetry issues. Rationale 2: The complete assessment findings will need to be shared with the healthcare provider but the nurse will need to have completed the assessment first to be able to provide adequate information. Rationale 3: Palpation of the scrotum is indicated to aid in determining other related abnormalities. Rationale 4: Asking the client for additional subjective information is not the priority action at this time. Global Rationale: The male scrotum is normally asymmetric due to the longer length of the left spermatic cord. This finding does not need further subjective data from the client or need to be reported to the healthcare provider. Although the scrotum does drop away from the body in elevated temperatures, this will not change its asymmetrical appearance.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.4: Differentiate normal from abnormal findings in physical assessment. Question 19 Type: MCSA The mother of a toddler expresses concern over her son “constantly playing with his penis and scrotum.” The nurse would correctly use which of the following responses to address the mother’s concern in this situation? 1. “These practices are normal for a child of this age.” 2. “Does she see his father doing the same actions?” 3. “Does he know what it means to be a boy or a girl?” 4. “These behaviors will go away as he gets older.” Correct Answer: 1 Rationale 1: Children often display curiosity with their genitals throughout all age spans. Parents should be reassured that this is normal behavior and part of the child’s growth and development. Rationale 2: The behaviors being displayed are normal for the age and are not a reflection of practices noticed by male role models. Rationale 3: The behaviors being displayed are normal for this age and do not reflect any sense of confusion concerning sexual identity. Rationale 4: Children often display curiosity with their genitals throughout all age spans. Parents should be reassured that this is normal behavior and part of the child’s growth and development. Global Rationale: Children often display curiosity with their genitals throughout all age spans. Parents should be reassured that this is normal behavior and part of the child’s growth and development. Observing that male role models have an interest in their genitals is not associated with the behaviors noted. The behaviors noted are not reflective of confusion relating to sexual identity. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 20 Type: MCSA

During the examination of an adult male the nurse notes thick, curly hair over the pubis area, a pear-shaped scrotum, and slightly darkened skin on the penis. The nurse would correctly choose which of the following actions? 1. Ask the client about recent illnesses. 2. Ask the client about sexual practices. 3. Notify the healthcare provider the findings. 4. Document the findings as normal. Correct Answer: 4 Rationale 1: There is no need to explore medical health history relating to this normal physical appearance. Rationale 2: The sexual practices of the client have no bearing on the normal findings. Rationale 3: The assessment findings are normal and do not warrant notification of the healthcare provider. Rationale 4: The findings are normal for a healthy adult male. Global Rationale: According to Tanner’s Maturation Stages in the male, the findings in this situation are appropriate for the adult male client. No further subjective information is required by the nurse. There is no need to explore medical health history relating to this normal physical appearance. The sexual practices of the client have no bearing on the normal findings. The healthcare provider does not need notification. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 21 Type: MCSA A 65-year-old client reports to the ambulatory care clinic for a routine physical examination. During the assessment the client reports plans to marry a much younger woman in the coming weeks. The client voices concerns about his ability to father children. What information may be provided by the nurse? 1. The client is facing infertility in the next few years as the majority of older men become infertile by age 70 years. 2. Although the production of sperm may be reduced in the older male, fathering a child is still possible with advancing age. 3. There are no changes to fertility of a man associated with aging.

4. Limited studies concerning the fertility of men are available and there is no definitive information available. Correct Answer: 2 Rationale 1: Sperm production begins to decline with middle age but the male is still able to produce adequate quantities of viable sperm to father children. A man of age 70 is able to father children. Rationale 2: Sperm production begins to decline with middle age but the male is still able to produce adequate quantities of viable sperm to father children. Rationale 3: Sperm production begins to decline with middle age but the male is still able to produce adequate quantities of viable sperm to father children. Rationale 4: There is adequate research available to prove the ability of older men to father children. Global Rationale: Sperm production begins to decline with middle age but the male is still able to produce adequate quantities of viable sperm to father children. A man of age 70 is able to father children. There is adequate research available to prove the ability of older men to father children. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings. Question 22 Type: MCMA The nurse is preparing a presentation on testicular cancer and wishes to target the age group most frequently affected. Which of the following settings would be considered appropriate to provide audiences considered to be at an increased risk for the disease? Standard Text: Select all that apply. 1. Elementary schools 2. Colleges 3. Cub Scout groups 4. High schools 5. Senior assisted living facilities Correct Answer: 2,4

Rationale 1: Elementary schools. Testicular cancer is the most common type of cancer in males between the ages of 20 and 35. It is recommended that testicular self-examinations be performed monthly beginning in adolescence and continue on through adulthood. Children in elementary schools are too young to initiate the examination. Rationale 2: Colleges. Testicular cancer is the most common type of cancer in males between the ages of 20 and 35. It is recommended that testicular self-examinations be performed monthly beginning in adolescence and continue on through adulthood. College-age males are in the target group and should be included. Rationale 3: Cub Scout groups. Testicular cancer is the most common type of cancer in males between the ages of 20 and 35. It is recommended that testicular self-examinations be performed monthly beginning in adolescence and continue on through adulthood. Cub scouts is a service group consisting primarily of elementary school–aged children. This group is too young to be considered in the target group. Rationale 4: High schools. Testicular cancer is the most common type of cancer in males between the ages of 20 and 35. It is recommended that testicular self-examinations be performed monthly beginning in adolescence and continue on through adulthood. Testicular cancer is the most common type of cancer in males between the ages of 20 and 35. It is recommended that testicular self-examinations be performed monthly beginning in adolescence and continue on through adulthood. Rationale 5: Senior Assisted Living Facilities. Testicular cancer is the most common type of cancer in males between the ages of 20 and 35. It is recommended that testicular self-examinations be performed monthly beginning in adolescence and continue on through adulthood. Global Rationale: Testicular cancer is the most common type of cancer in males between the ages of 20 and 35. Self-examinations should begin in adolescence and continue throughout adulthood. Populations of the target subjects would be available in colleges and high schools. Elementary school students are too young for this level of education. The educational process should begin before a male reaches advanced age. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.6: Discuss the objectives for the male reproductive system as presented in Healthy People 2020. Question 23 Type: MCMA The nurse is interviewing a male client with an elevated prostate specific antigen level (PSA). The nurse would correlate potential risk factors for this client by asking which of the following questions? Standard Text: Select all that apply. 1. “Do you have a positive family history for prostate cancer?” 2. “Do you masturbate?” 3. “How frequently do you have sexual intercourse?”

4. “Do you smoke?” 5. “Do you have a history of urinary tract infections?” Correct Answer: 1,4 Rationale 1: “Do you have a positive family history for prostate cancer?” Family history is a significant risk factor for the development of prostate cancer. Rationale 2: “Do you masturbate?” Masturbation is not considered a risk factor for the development of prostate cancer. Rationale 3: “How frequently do you have sexual intercourse?” The frequency of sexual intercourse does not have a bearing on the occurrence of prostate cancer. Rationale 4: “Do you smoke?” Smoking has been linked to the development of prostate cancer. Rationale 5: “Do you have a history of urinary tract infections?” Urinary tract infections are not linked to the incidence of prostate cancer. Global Rationale: Familial links are noted for the development of prostate cancer. Smoking is also identified as a risk for the development of prostate cancer. Masturbation, the frequency of sexual intercourse and the incidence of urinary tract infections is not associated with the development of prostate cancer. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.6: Discuss the objectives for the male reproductive system as presented in Healthy People 2020. Question 24 Type: MCSA The nurse is conducting a health interview for a 55-year-old client who has presented to the clinic for an annual physical examination. The client questions the need to begin screening for prostate cancer at this examination. What response by the nurse is indicated? 1. “Unless you are at an increased risk for the development of prostate cancer no additional screening indicated.” 2. “PSA screening tests should be performed once you reach age 75.” 3. “You need to begin having an annual prostate examination.” 4. “A cystoscopy should be performed annually to assess for prostate changes at age 55.” Correct Answer: 3

Rationale 1: Annual prostate screening is recommended to begin at age 50 years. Rationale 2: PSA screening tests are not recommended for men over age 75 years. Rationale 3: Annual prostate screening is recommended to begin at age 50 years. Rationale 4: The cystoscopy is a diagnostic test that is used to assess the inside of the bladder. It is not used to assess for the presence of prostate cancer. Global Rationale: Annual prostate examination is recommended for males after the age of 50. The United States Preventive Task Force (USPSTF) (2008) has issued recommendations regarding the use of the prostate specific antigen (PSA) screening. The USPSTF recommends against PSA screening in males 75 years of age and older. In men younger than 75 the recommendations are to review individual risk factors to determine the use of the test. Cystoscopy is a diagnostic test that allows for a scope to be inserted through the urethra to view the bladder. It is not used to diagnose prostate cancer. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.6: Discuss the objectives for the male reproductive system as presented in Healthy People 2020. Question 25 Type: MCSA The nurse is assessing a male client who has epididymitis. The nurse would appropriately educate the client using which of the following statements? 1. “You will have a decrease in testosterone production.” 2. “Your sperm maturity may be affected.” 3. “There will be a decrease in blood flow to your penis.” 4. “There may be erectile difficulties.” Correct Answer: 2 Rationale 1: Testosterone is produced within the testes. Inflammation of the epididymis will not impact testosterone production. Rationale 2: The final storage area for sperm is the epididymis. Inflammation of this area may impact sperm maturity. Rationale 3: The epididymis does not impact blood flow to the penis. Rationale 4: The epididymis does not have a role in the achievement of an erection.

Global Rationale: The epididymis does not produce testosterone. The epididymis is the final area for the storage and maturation of sperm. Inflammation of the epididymis can impact the sperm’s maturity. The epididymis does not impact the blood flow to the penis. The epididymis does not have an influence on the ability to achieve an erection. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical assessment of the male reproductive system. Question 26 Type: MCSA During the well-child assessment on a 2-year-old male the nurse notes that the testes are not descended. The nurse would correctly choose which of the following actions? 1. Report the finding to the healthcare provider. 2. Ask the parent if the child has had any surgeries. 3. Proceed with palpation of the scrotum. 4. Inquire about the child’s voiding patterns. Correct Answer: 1 Rationale 1: Undescended testes, called cryptorchidism, is a common finding, especially if the infant is preterm. The testes should descend spontaneously within the first year of life. If both testes do not descend, the male will be infertile and will be at a greater risk for the development of testicular cancer. Rationale 2: The presence of surgical histories will not influence the condition or the actions that must be taken next. Rationale 3: Palpation of scrotum will not promote the testicles to descend. The healthcare provider must be notified. Rationale 4: Voiding patterns are not related to the occurrence of cryptorchidism. Global Rationale: Undescended testes, or cryptochidism, is common in preterm infants, but should resolve spontaneously by 1 year of age. If unresolved, the condition can lead to infertility in the male and at risk for testicular cancer. This abnormal finding should be reported to the healthcare provider. Previous surgeries and voiding patterns are not relevant to this situation, and palpation will not be possible. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical assessment of the male reproductive system. Question 27 Type: MCSA A couple is seeking infertility information from the nurse. Which of the following statements made by the couple would indicate the need for intervention by the nurse? 1. “We have been to two doctors already.” 2. “We have intercourse at least three times a week.” 3. “We are using temperature tracking for ovulation prediction.” 4. “We have been trying to conceive for a year.” Correct Answer: 4 Rationale 1: The number of healthcare providers being seen by the family are not relevant to the nurse’s immediate actions. Rationale 2: The couple is engaging in sexual intercourse. This indicates a lack of intercourse should not be of issue. Rationale 3: The use of the basal body temperature to assess for ovulation is recommended as an initial step in attempting to conceive. Rationale 4: Couples are not considered for infertility treatment until they have tried to conceive for at least one year. Global Rationale: Couples are not considered for infertility treatment until they have tried to conceive for at least one year. Temperature tracking for ovulation and frequent intercourse are suggested when trying to conceive. The number of healthcare providers the couple has been to is not relevant information in this situation. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical assessment of the male reproductive system. Question 28 Type: MCSA 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. Medicate for pain with narcotics. 2. Prepare for surgery. 3. Elevate the scrotum. 4. Administer anti-inflammatory medications. Correct Answer: 2 Rationale 1: Medication for pain with narcotics may be ordered by the healthcare provider. It does not, however, present a higher priority than preparing the client for surgery. Rationale 2: Torsion of the spermatic cord requires immediate surgical intervention, making this the priority for the nurse in this situation. Rationale 3: The scrotum may be elevated after the procedure but elevation is not a priority in the preoperative period. Rationale 4: The administration of anti-inflammatory medications is not indicated for this client. Global Rationale: Torsion of the spermatic cord requires immediate surgical intervention, making this the priority for the nurse in this situation. Medication for pain with narcotics may be ordered by the healthcare provider. It does not, however, present a higher priority than preparing the client for surgery. The scrotum may be elevated after the procedure but elevation is not a priority in the preoperative period. The administration of antiinflammatory medications is not indicated for this client. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical assessment of the male reproductive system. Question 29 Type: MCSA 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 was treated for gonorrhea 2 years ago. 2. The client has a history of genital herpes simplex. 3. The client’s medical history indicates a past history of marijuana use. 4. The client works in a paint manufacturing company.

Correct Answer: 4 Rationale 1: Gonorrhea in a male has not been linked to infertility. In addition, there are no factors provided to infer that damage has resulted from the disease. Rationale 2: Men with genital herpes simplex are not infertile. Rationale 3: A history of marijuana use is not associated with male-related infertility. Rationale 4: Chronic exposure to chemicals has been implicated in the development of male caused infertility. Global Rationale: The responsibility of the nurse includes making additional inquiries on factors that may be related to the concerns associated with infertility. Chronic exposure to chemicals has been implicated in the development of male-caused infertility. Gonorrhea in a male has not been linked to infertility. In addition, there are no factors provided to infer that damage has resulted from the disease. Men with genital herpes simplex are not infertile. A history of marijuana use is not associated with male-related infertility. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical assessment of the male reproductive system. Question 30 Type: MCSA 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. Administration of estrogen to reduce the impact of escalating testosterone levels 2. Continued observation of the rate of maturation for the next 6 to 9 months 3. Referral to an endocrinologist 4. Reduction of processed foods in the diet to reduce hormone exposure Correct Answer: 3 Rationale 1: Estrogen is not administered to males to manage precocious puberty. A prompt diagnosis of the condition is warranted. Rationale 2: A prompt diagnosis of the condition is warranted. It would be inappropriate to continue observation for the next 6 to 9 months.

Rationale 3: Precocious puberty may be idiopathic or caused by a genetic trait, lesions in the pituitary gland or hypothalamus, or testicular tumors. Referral to an endocrinologist may be required for definitive diagnosis. Rationale 4: While processed foods may contain excess hormones and chemicals the child in the scenario will need a prompt diagnosis of this condition. Global Rationale: Precocious puberty is an endocrine disorder characterized by the development of adult male characteristics in males under age 10. It includes dense pubic hair, penile enlargement, and enlargement of the testes. Precocious puberty may be idiopathic or caused by a genetic trait, lesions in the pituitary gland or hypothalamus, or testicular tumors. Referral to an endocrinologist may be required for definitive diagnosis. Estrogen is not administered to males to manage precocious puberty. A prompt diagnosis of the condition is warranted. It would be inappropriate to continue observation for the next 6 to 9 months. While processed foods may contain excess hormones and chemicals the child in the scenario will need a prompt diagnosis of this condition. Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical assessment of the male reproductive system.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 22 Question 1 Type: HOTSPOT A teenaged client has been brought to the clinic with complaints of pain. After an examination it was determined that the client has an inflamed Bartholin’s cyst. After the examination the client and her mother ask the nurse to show them the location of the gland involved. Mark an “X” on the location of the Bartholin’s gland.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : 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. Global Rationale: Cognitive Level: Remembering Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive system. Question 2 Type: HOTSPOT The nurse is caring for a pregnant client. The nurse notes the healthcare provider has documented the client has a positive Goodell’s sign. Mark an “X” on the area to which this refers.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : Goodell’s sign refers to the softening of the cervix during pregnancy. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive system. Question 3 Type: MCMA

The nurse is preparing to assess a female client’s external genitalia. The structures included in this assessment would be: Standard Text: Select all that apply. 1. Vagina 2. Cervix 3. Clitoris 4. Labia majora 5. Labia minora Correct Answer: 3,4,5 Rationale 1: Vagina. The internal female reproductive organs are the vagina, uterus, cervix, fallopian tubes, and ovaries. Rationale 2: Cervix. The internal female reproductive organs are the vagina, uterus, cervix, fallopian tubes, and ovaries. Rationale 3: Clitoris. Female external genitalia include the mons pubis, labia, glands, clitoris, and perianal area. Rationale 4: Labia minora. Female external genitalia include the mons pubis, labia, glands, clitoris, and perianal area. Rationale 5: Labia majora. Female external genitalia include the mons pubis, labia, glands, clitoris, and perianal area. Global Rationale: The female external genitalia include the clitoris, labia majora, and the labia minora. The vagina and cervix are considered to be internal genitalia. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive system. Question 4 Type: MCSA The nurse notes a forward-tilted uterus with a downward-tilted cervix when examining a female client. The nurse would correctly document which of the following findings in this situation? 1. Anteflexion

2. Retroflexion 3. Anteversion 4. Midposition Correct Answer: 3 Rationale 1: The uterus in anteflexion is folded forward at a 90-degree angle with the cervix is tilted downward. Rationale 2: The retroverted uterus is tilted backward with the cervix tilted upward. Rationale 3: Normal variations of uterine position include anteversion in which the uterus is tilted forward, the cervix is tilted downward. Rationale 4: The uterus in midposition lies parallel to the tailbone with the cervix pointed straight. Global Rationale: Normal variations of uterine position include anteversion (the uterus is tilted forward, the cervix is tilted downward), midposition (the uterus lies parallel to the tailbone, the cervix is pointed straight), and retroversion (the uterus is tilted backward, the cervix is tilted upward). Abnormal variations of uterine position include anteflexion (the uterus is folded forward at a 90-degree angle, the cervix is tilted downward), and retroflexion (the uterus is folded backward at a 90-degree angle, the cervix is tilted upward). Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive system. Question 5 Type: MCSA The nurse notes that the uterus is folded backward with the cervix tilted upward when examining a female client. The nurse would correctly document which of the following findings in this situation. 1. Retroversion 2. Retroflexion 3. Midposition 4. Anteflexion Correct Answer: 2 Rationale 1: The retroversion positioned uterus is tilted backward with the cervix tilted upward. Rationale 2: The retroflexion uterus is folded backward at a 90-degree angle with the cervix tilted upward.

Rationale 3: The midposition uterus lies parallel to the tailbone, the cervix is pointed straight. Rationale 4: The anteversion uterus is tilted forward with the cervix tilted downward. Global Rationale: Normal variations of uterine position include anteversion (the uterus is tilted forward, the cervix is tilted downward), midposition (the uterus lies parallel to the tailbone, the cervix is pointed straight), and retroversion (the uterus is tilted backward, the cervix is tilted upward). Abnormal variations of uterine position include anteflexion (the uterus is folded forward at a 90-degree angle, the cervix is tilted downward), and retroflexion (the uterus is folded backward at a 90-degree angle, the cervix is tilted upward). Fibroids are benign tumors located within the uterine walls. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive system. Question 6 Type: HOTSPOT The nurse is reviewing the technique utilized to obtain an endocervical specimen on a client. Mark with an “X” the location from which the specimen will be obtained.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The comprehensive pap smear will include swabbed specimens from the endocervical region.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.2: Explain client preparation for the assessment of the reproductive system. Question 7 Type: MCMA The nurse is preparing to examine the female reproductive system of a client. The nurse would anticipate using which of the following assessment techniques? Standard Text: Select all that apply. 1. Inspection 2. Palpation 3. Percussion 4. Auscultation 5. Aspiration Correct Answer: 1,2 Rationale 1: Inspection. When completing the assessment of the female reproductive system the examiner will inspect the external genitalia. Rationale 2: Palpation. Palpation will be used in the examination of the female reproductive system. The abdomen will be palpated to assess for the size and shape of the internal organs. Rationale 3: Percussion. Percussion will not be employed in the assessment of the female reproductive system. Percussion will be used to assess the gastrointestinal and pulmonary systems. Rationale 4: Auscultation. Auscultation will not be used to assess the female reproductive system. Auscultation will be used to assess the cardiovascular, pulmonary, and gastrointestinal systems. Rationale 5: Aspiration. Aspiration will not be used to assess the female reproductive system. Aspiration may be performed to obtain a sample. Global Rationale: The physical assessment techniques of inspection and palpation are used in the examination of the female reproductive system. When completing the assessment of the female reproductive system the examiner will inspect the external genitalia. Palpation will be used in the examination of the female reproductive system. The abdomen will be palpated to assess for the size and shape of the internal organs. Percussion will not be employed in the assessment of the female reproductive system. Percussion will be used to assess the

gastrointestinal and pulmonary systems. Auscultation will not be used to assess the female reproductive system. Auscultation will be used to assess the cardiovascular, pulmonary, and gastrointestinal systems. Aspiration will not be used to assess the female reproductive system. Aspiration may be performed to obtain a sample. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.2: Explain client preparation for the assessment of the reproductive system. Question 8 Type: MCSA The nurse is examining a 65 year old and palpates a mobile, smooth, round-shaped mass in the left lower abdominal quadrant. The nurse would correctly choose which of the following actions next? 1. Ask the client if she is menstruating. 2. Report the findings to the healthcare provider. 3. Re-examine the area using a vaginal speculum. 4. Ask the client if she could be pregnant. Correct Answer: 2 Rationale 1: The client in this scenario is elderly. Menstruation is not a viable option. Rationale 2: In women who have been postmenopausal for more than 2.5 years, palpable ovaries are considered abnormal as the ovaries would normally atrophy with the decrease in estrogen. Rationale 3: The ovary cannot be viewed with a vaginal speculum. Rationale 4: The age of the client would not support a likely pregnancy for the client in the scenario. In addition, the pregnant uterus would not be palpated in the area described. Global Rationale: In women who have been postmenopausal for more than 2.5 years, palpable ovaries are considered abnormal as the ovaries would normally atrophy with the decrease in estrogen. The ovary cannot be viewed with a vaginal speculum, and a pregnant uterus would not be palpated in this area. Menstruation is not relevant to this situation. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.3: Develop questions to be used when conducting the focused interview. Question 9

Type: MCSA The nurse is performing a gynecological examination and is ready to insert the speculum. The nurse would correctly insert the speculum at which of the following angles with the client in the lithotomy position? 1. 90 degrees 2. 45 degrees 3. Straight down 4. Straight up Correct Answer: 2 Rationale 1: The speculum should be inserted at a 45-degree downward angle. This angle matches the downward slope of the vagina when the client is in the lithotomy position. Rationale 2: The speculum should be inserted at a 45-degree downward angle. This angle matches the downward slope of the vagina when the client is in the lithotomy position. Rationale 3: The speculum should be inserted at a 45-degree downward angle. This angle matches the downward slope of the vagina when the client is in the lithotomy position. Rationale 4: The speculum should be inserted at a 45-degree downward angle. This angle matches the downward slope of the vagina when the client is in the lithotomy position. Global Rationale: The speculum should be inserted at a 45-degree downward angle. This angle matches the downward slope of the vagina when the client is in the lithotomy position. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.4: Describe techniques required for assessment of the female reproductive system. Question 10 Type: MCMA The nurse is preparing to perform an endocervical swab and needs to choose the most effective equipment to collect this specimen. The nurse would have which of the following ready for this procedure? Standard Text: Select all that apply. 1. Microscopic slides 2. Saline

3. Cytobrush 4. Cotton applicator 5. Fixative Correct Answer: 1,3,5 Rationale 1: Microscopic slides. The slides will be used to place the specimen on. Rationale 2: Saline. Saline is used to moisten a cotton tipped applicator but is not needed with the cytobrush. Rationale 3: Cytobrush. The cytobrush is preferred to obtain the endocervical cells. Rationale 4: Cotton applicator. The use of the cotton application is not as highly recommended as the cytobrush. The endocervical cells will not adhere as well to the cotton-tipped applicator. Rationale 5: Fixative. A fixative is a solution used to secure the specimen. Global Rationale: When preparing to obtain an endocervical swam specimen the nurse will need to have microscopic slides, cytobrush, and a fixative. The slides will be used to place the specimen on. The cell specimens are obtained using a cytobrush. The cotton applicator will not be used in place of the cytobrush as it is not as effective in obtaining cells. Saline is used to moisten a cotton-tipped applicator but not used with the cytobrush. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.4: Describe techniques required for assessment of the female reproductive system. Question 11 Type: MCSA 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. Defer the cervical scrape. 2. Use the vaginal wall for the cervical scrape. 3. Tell the client an examination is not needed. 4. Use the surgical stump for the cervical scrape. Correct Answer: 4

Rationale 1: Clients who have had hysterectomies should have the surgical stump scraped as part of the examination. Deferring the cervical assessment could result in the omission of important information for the comprehensive care of the client. Rationale 2: Specimens from the vaginal walls are indicated but do not replace the need to have cells obtained from the cervical stump. Rationale 3: Clients that have had hysterectomies should have the surgical stump scraped as part of the examination. Rationale 4: Clients that have had hysterectomies should have the surgical stump scraped as part of the examination. Global Rationale: Clients who have had hysterectomies should have the surgical stump scraped as part of the examination. Deferring the scrape, using the walls of the vagina, or telling the client the examination is not needed would reduce the client’s ability to have a comprehensive pelvic examination. Important cellular specimens must be obtained from the cervical stump. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.4: Describe techniques required for assessment of the female reproductive system. Question 12 Type: MCSA The nurse assisting the healthcare provider who is performing a bimanual examination on an extremely obese client. The healthcare provider is unable to palpate the uterus. Which of the following actions would most likely be selected in this situation? 1. Defer the examination. 2. Schedule an X-ray. 3. Schedule an ultrasound. 4. Ask the client if she has had recent problems. Correct Answer: 3 Rationale 1: Forgoing an examination as a result of difficulties encountered is not a responsible action. The nurse has a responsibility to utilize other methods available as indicated. Rationale 2: The use of an X-ray is not the best diagnostic test to review the condition of soft tissue organs and surrounding tissue.

Rationale 3: In an obese female palpation of the uterus may be difficult. An ultrasound would allow for examination of the female reproductive organs. Rationale 4: The size of the client is the most likely cause of the inability to palpate the uterus. A discussion of recent problems is a part of the assessment but it does not reduce the need to discuss obtaining the ultrasound. Global Rationale: In the obese female, it may be difficult to clearly differentiate the uterine structures and an ultrasound may be needed. Obtaining an ultrasound can only be done after consulting with the healthcare provider about the findings. The remaining choices are incorrect for this situation. An X-ray is not the best diagnostic test to review the condition of soft tissue organs and surrounding tissue. Deferring the examination does not meet the needs of the client. Determining the client’s recent health history does not meet the needs of the client in having the uterus evaluated. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.4: Describe techniques required for assessment of the female reproductive system. Question 13 Type: MCSA The nurse is examining a pregnant client and notes the cervix is soft in texture and nontender. The nurse would correctly document which of the following conditions in this situation? 1. Nabothian cyst 2. Chadwick’s sign 3. Hegar’s sign 4. Goodell’s sign Correct Answer: 4 Rationale 1: Nabothian cysts are yellow and nodular and are benign areas that may appear after childbirth. Rationale 2: Chadwick’s sign, also occurring during pregnancy, is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Rationale 3: Hegar’s sign refers to the softening of the lower uterine segemt during pregnancy. Rationale 4: During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodell’s sign. Global Rationale: During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodell’s sign. Chadwick’s sign, also occurring during pregnancy, is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Hegar’s sign refers to a

softening of the lower uterine segment during pregnancy. Nabothian cysts are yellow and nodular and are benign areas that may appear after childbirth. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system. Question 14 Type: MCSA The nurse is examining a pregnant client and notes the cervix has a bluish-purple change in coloration. The nurse would correctly document which of the following conditions in this situation? 1. Nabothian cyst 2. Goodell’s sign 3. Chadwick’s sign 4. Bloody show Correct Answer: 3 Rationale 1: Nabothian cysts are yellow and nodular and are benign areas that may appear after childbirth. Rationale 2: Vascularity of the cervix also contributes to the softening of the cervix, and is called Goodell’s sign. Rationale 3: Chadwick’s sign appears during pregnancy and is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Rationale 4: Expulsion of the mucous plug at the endocervical canal produces a bloody show at the initiation of labor. Global Rationale: Chadwick’s sign appears during pregnancy and is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Nabothian cysts are yellow and nodular and are benign areas that may appear after childbirth. Vascularity of the cervix also contributes to the softening of the cervix, and is called Goodell’s sign. Nabothian cysts are yellow and nodular and are benign areas that may appear after childbirth. Expulsion of the mucous plug at the endocervical canal produces a bloody show at the initiation of labor. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 15 Type: MCSA 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. Contact dermatitis 2. Yeast infection 3. Herpes infection 4. Venereal warts Correct Answer: 2 Rationale 1: Contact dermatitis is characterized by reddened lesions that weep and form crusts. Rationale 2: Yeast infections are the most common female genital infection and can produce redness, pruritis, and cheese-like discharge. Rationale 3: Herpes infection causes small, red, painful ulcerations. Rationale 4: Venereal warts appear as cauliflower-shaped, raised, moist papules. Global Rationale: Yeast infections are the most common female genital infection and can produce redness, pruritis, and cheese-like discharge. Contact dermatitis is characterized by reddened lesions that weep and form crusts. Herpes infection causes small, red, painful ulcerations. Venereal warts appear as cauliflower-shaped, raised, moist papules. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system. Question 16 Type: MCSA The nurse is examining a female client and notes a greenish discharge with a foul odor. The client also exhibits guarding of the abdomen. The nurse would suspect which of the following conditions in this situation? 1. Trichomoniasis 2. Herpes infection

3. Gonorrhea 4. Bacterial vaginosis Correct Answer: 3 Rationale 1: Frothy yellow-green discharge is seen in trichomoniasis. Rationale 2: Herpes infection produces red, painful vesicles with localized swelling. Rationale 3: Green discharge that has a foul smell is associated with gonorrhea, which may spread to the abdominal cavity to cause pelvic inflammatory disease. Rationale 4: Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy odor. Global Rationale: Green discharge that has a foul smell is associated with gonorrhea, which may spread to the abdominal cavity to cause pelvic inflammatory disease. Frothy yellow-green discharge is seen in trichomoniasis. Herpes infection produces red, painful vesicles with localized swelling. Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy odor. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system. Question 17 Type: MCSA 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. Bartholin’s abscess 4. Contact dermatitis Correct Answer: 1 Rationale 1: Genital warts present as raised, cauliflower-shaped papules. Rationale 2: Herpes infection produces red, painful vesicles with localized swelling.

Rationale 3: Bartholin’s abscess produces inflammatory signs such as redness and warm skin. Bartholin’s abscess produces inflammatory signs such as redness and warm skin. Rationale 4: Contact dermatitis produces red, weepy rashes. Global Rationale: Genital warts present as raised, cauliflower-shaped papules as described. Herpes infection produces red, painful vesicles with localized swelling. Bartholin’s abscess produces inflammatory signs such as redness and warm skin. Contact dermatitis produces red, weepy rashes. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system. Question 18 Type: MCSA The nurse notes documentation in the client’s history and physical of a nontender protrusion into the anterior vaginal wall. The nurse would suspect which of the following conditions in this situation? 1. Inflammation of the Skene’s gland 2. Prolapsed uterus 3. Rectocele 4. Cystocele Correct Answer: 4 Rationale 1: The Skene’s glands are examined by palpation on both sides of the urethra. Rationale 2: A prolapsed uterus may protrude from the vaginal wall, and may occur with or without straining. Rationale 3: A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall. Rationale 4: A cystocele is a hernia that is formed when the urinary bladder is pushed into the vaginal wall. Global Rationale: A cystocele is a hernia that is formed when the urinary bladder is pushed into the vaginal wall. The Skene’s glands are examined by palpation on both sides of the urethra. A prolapsed uterus may protrude from the vaginal wall, and may occur with or without straining. A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system. Question 19 Type: MCSA The nurse is reading the history and physical and notes documentation of a protrusion into the posterior vaginal wall. The nurse would suspect which of the following conditions in this situation? 1. Ovarian cyst 2. Bartholin’s gland infection 3. Cystocele 4. Rectocele Correct Answer: 4 Rationale 1: Ovarian cysts cause inflammation and tenderness upon examination. Rationale 2: The Bartholin’s glands are palpated by gently squeezing the posterior region of the labia majora. Rationale 3: A cystocele is a hernia that is formed when the urinary bladder is pushed into the vaginal wall. Rationale 4: A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall. Global Rationale: A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall. Ovarian cysts cause inflammation and tenderness upon examination. The Bartholin’s glands are palpated by gently squeezing the posterior region of the labia majora. A cystocele is a hernia that is formed when the urinary bladder is pushed into the vaginal wall. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system. Question 20 Type: MCSA The nurse is interviewing a female client that reports a grayish discharge with a fishy odor. The nurse would suspect which of the following conditions in this situation? 1. Bacterial vaginosis

2. Chlamydia 3. Genital warts 4. Gonorrhea Correct Answer: 1 Rationale 1: Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy odor. Rationale 2: A yellow discharge can be noted in a chlamydia infection. Rationale 3: Genital warts are raised, moist, cauliflower-shaped papules. Rationale 4: Gonorrhea is associated with a foul-smelling discharge. Global Rationale: Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy odor. A yellow discharge can be seen in chlamydial infection. Genital warts are raised, moist, cauliflower-shaped papules. Green discharge that has a foul smell is associated with gonorrhea. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system. Question 21 Type: MCSA The nurse is interviewing a female client who reports a frothy, yellow-green discharge. The nurse would suspect which of the following conditions in this situation? 1. Vaginitis 2. Trichomoniasis 3. Gonorrhea 4. Chlamydia Correct Answer: 2 Rationale 1: Vaginitis indicates a nonspecific inflammation of the vagina. Rationale 2: Frothy yellow-green discharge is seen in trichomoniasis. Rationale 3: Green discharge that has a foul smell is associated with gonorrhea.

Rationale 4: A yellow discharge can be seen in chlamydial infection. Global Rationale: Frothy yellow-green discharge is seen in trichomoniasis. Vaginitis indicates a nonspecific inflammation of the vagina. Green discharge that has a foul smell is associated with gonorrhea. Green discharge that has a foul smell is associated with gonorrhea. A yellow discharge can be seen in chlamydial infection. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system. Question 22 Type: MCSA The nurse is examining the external genitalia of a female client and notes small vesicular lesions that are painful. The nurse would suspect which of the following conditions in this situation? 1. Genital warts 2. Herpes infection 3. Bartholin’s abscess 4. Contact dermatitis Correct Answer: 2 Rationale 1: Genital warts produce cauliflower-like lesions. Rationale 2: Herpes infection produces red, painful vesicles with localized swelling. Rationale 3: Bartholin’s abscess produces inflammatory signs, such as redness and warm skin. Rationale 4: Contact dermatitis produces red, weepy rashes. Global Rationale: Herpes infection produces red, painful vesicles with localized swelling. Genital warts produce cauliflower-like lesions. Bartholin’s abscess produces inflammatory signs, such as redness and warm skin. Contact dermatitis produces red, weepy rashes. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 23 Type: MCSA The nurse is examining the external genitalia of a female client and notes draining papules. The nurse would suspect which of the following conditions in this situation? 1. Genital warts 2. Herpes infection 3. Syphilitic lesion 4. Contact dermatitis Correct Answer: 3 Rationale 1: Genital warts produce cauliflower-like lesions. Rationale 2: Herpes infection produces red, painful vesicles with localized swelling. Rationale 3: Syphilitic lesions are painless papules that may begin to produce drainage. Rationale 4: Contact dermatitis produces red, weepy rashes. Global Rationale: Syphilitic lesions are painless papules that may begin to produce drainage. Genital warts produce cauliflower-like lesions. Herpes infection produces red, painful vesicles with localized swelling. Contact dermatitis produces red, weepy rashes. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system. Question 24 Type: MCSA 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. “My periods may be irregular and less frequent.” 2. “Night sweats and hot flashes are commonly experienced.” 3. “My mood changes are a normal part of menopause.” 4. “Vaginal dryness may occur during menopause.”

Correct Answer: 1 Rationale 1: Menopause is said to have occurred when the female has not experienced a period in over one year. Rationale 2: As estrogen levels decline, symptoms include night sweats, hot flashes, mood changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete. Rationale 3: As estrogen levels decline, symptoms include night sweats, hot flashes, mood changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete. Rationale 4: As estrogen levels decline, symptoms include night sweats, hot flashes, mood changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete. Global Rationale: Menopause is said to have occurred when the female has not experienced a period in over one year. As estrogen levels decline, symptoms include night sweats, hot flashes, mood changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental variations in assessment and findings. Question 25 Type: MCSA The nurse is interviewing an elderly female client. Which of the following statements made by the client would cause intervention by the nurse? 1. “I use a lubricant for sex to help with dryness.” 2. “I take hormone pills to help with my hot flashes.” 3. “My periods stopped for 5 years, but recently restarted.” 4. “I don’t have a desire for sex very often, but neither does my husband.” Correct Answer: 3 Rationale 1: The use of lubrication for sexual intimacy is normal due to vaginal dryness, although libido may be diminished in both the male and female. Rationale 2: The use of estrogen replacement therapy can alleviate symptoms related to night sweats, hot flashes, and mood changes. Rationale 3: Women may assume that postmenopausal bleeding is normal and ignore it, but this may be suggestive of inadequate estrogen therapy or endometrial cancer, and follow-up is required.

Rationale 4: The use of lubrication for sexual intimacy is normal due to vaginal dryness, although libido may be diminished in both the male and female. Global Rationale: Women may assume that postmenopausal bleeding is normal and ignore it, but this may be suggestive of inadequate estrogen therapy or endometrial cancer, and follow-up is required. The use of lubrication for sexual intimacy is normal due to vaginal dryness, although libido may be diminished in both the male and female. The use of estrogen replacement therapy can alleviate symptoms related to night sweats, hot flashes, and mood changes. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental variations in assessment and findings. Question 26 Type: MCMA The nurse is examining an adolescent female and notes no pubic hair on the pubis area. The nurse would correctly choose which of the following actions? Standard Text: Select all that apply. 1. Ask the client if she is menstruating. 2. Examine the client for breast buds. 3. Report the findings to the healthcare provider. 4. Document the findings as normal. 5. Assess the client’s dietary intake. Correct Answer: 1,2,3 Rationale 1: Ask the client if she is menstruating. The presence or absence of menstrual history will aid in the determination of hormonal function. Rationale 2: Examine the client for breast buds. The presence or absence of breast buds will aid in the confirmation of the maturity of secondary sexual characteristics. Rationale 3: Report the findings to the healthcare provider. Abnormalities may be indicative of endocrine pathology and need to be reported to the healthcare provider for follow-up. Rationale 4: Document the findings as normal. According to Tanner’s Maturation Stages in the female, the findings in this situation are not normal for the adolescent female client. The adolescent female should have fine, sparse hair beginning at the labia and rising up the pubis.

Rationale 5: Assess the client’s dietary intake. Dietary intake information in the client who presents with physical immaturities in the event they also exhibit signs of nutritional deficiencies. There is no supportive information indicating that there are nutritional needs unmet. Global Rationale: According to Tanner’s Maturation Stages in the female, the findings in this situation are not normal for the adolescent female client. The adolescent female should have fine, sparse hair beginning at the labia and rising up the pubis. Abnormalities may be indicative of endocrine pathology and need to be reported to the healthcare provider for follow-up. Potentially related factors will need to be investigated. Subjective data related to menstruation are relevant to the situation. The presence or absence of menstrual history will aid in the determination of hormonal function. The presence or absence of breast buds will aid in the confirmation of the maturity of secondary sexual characteristics. Dietary intake information in the client who presents with physical immaturities may be reviewed in the event they also exhibit signs of nutritional deficiencies. There is no supportive information indicating that there are nutritional needs unmet. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental variations in assessment and findings. Question 27 Type: MCSA The nurse is examining an adult female and notes thick, coarse pubic hair covering the pubis and extending to the thighs. The nurse would correctly choose which of the following actions? 1. Ask the client if she has started menstruation. 2. Report the findings to the healthcare provider. 3. Document the findings as normal. 4. Ask the client if she is sexually active. Correct Answer: 3 Rationale 1: The client’s physical appearance indicates the correct level of maturation. Information concerning menstruation is not needed. Rationale 2: In the presence of normal findings the healthcare provider does not need notification. Rationale 3: According to Tanner’s Maturation Stages in the female, the findings in this situation are appropriate for the adult female client. No further subjective information is required by the nurse. The nurse should document the findings. Rationale 4: Information concerning the client’s level of sexual activity is not relevant to the client in this scenario.

Global Rationale: According to Tanner’s Maturation Stages in the female, the findings in this situation are appropriate for the adult female client. No further subjective information is required by the nurse. The nurse should document the findings. The client’s physical appearance indicates the correct level of maturation. Information concerning menstruation is not needed. In the presence of normal findings the healthcare provider does not need notification. Information concerning the client’s level of sexual activity is not relevant to the client in this scenario. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental variations in assessment and findings. Question 28 Type: MCSA The community health nurse is preparing a presentation concerning the sexual health of teenaged girls. The objectives of Healthy People 2020 are being used as guidelines. When planning the offering which of the following should be included? 1. Increase the number of teens who are using oral contraceptives. 2. Increase the number of teens who utilize relationship counseling services. 3. Increase the number of teens who are tested for HIV. 4. Increase the number of teens who understand their reproductive functions. Correct Answer: 3 Rationale 1: The goals of Healthy People 2020 seek to increase the proportion of adolescents who abstain from sexual intercourse or use condoms if sexually active and to increase the percentage of adolescents who have been tested for HIV. There are no provisions to dictate the use of oral contraceptives. Rationale 2: Relationship counseling services are not included in the Healthy People 2020 objectives. Rationale 3: The goals of Healthy People 2020 seek to increase the proportion of adolescents who abstain from sexual intercourse or use condoms if sexually active and to increase the percentage of adolescents who have been tested for HIV. Rationale 4: The understanding of reproductive functions is not direct objectives of Healthy People 2020. Global Rationale: The goals of Healthy People 2020 seek to increase the proportion of adolescents who abstain from sexual intercourse or use condoms if sexually active and to increase the percentage of adolescents who have been tested for HIV. There are no provisions to dictate the use of oral contraceptives. Relationship counseling services are not included in the Healthy People 2020 objectives. The understanding of reproductive functions is not a direct objective of Healthy People 2020.

Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.7: Discuss objectives related to women’s health as stated in Healthy People 2020. Question 29 Type: MCSA The nurse suspects a gonorrheal infection in a client during an examination. Which of the following would be a priority action for the nurse? 1. Counsel regarding safe sex practices. 2. Obtain history of sexual contacts. 3. Obtain a culture. 4. Document the findings. Correct Answer: 3 Rationale 1: The interaction between the nurse and client will include a discussion about safe sex practices. The discussion, however, of safe sexual practices is not a priority as the client has presented with a potential sexually transmitted infection. Rationale 2: A listing of sexual contacts may be indicated in the event the disease is positively identified. At this time this step is premature pending the outcome of the diagnostic tests. Rationale 3: Obtaining a culture of the potential infection is indicated as the priority. The findings of the culture will be used to determine the next actions of the nurse. Rationale 4: The nurse will need to document the findings. It is most important to obtain the culture. Global Rationale: The priority for the nurse in this situation is to obtain a culture of any discharge present so a definitive diagnosis can be made. The interaction between the nurse and client will include a discussion about safe sex practices. The discussion, however, of safe sexual practices is not a priority as the client has presented with a potential sexually transmitted infection. A listing of sexual contacts may be indicated in the event the disease is positively identified. At this time this step is premature pending the outcome of the diagnostic tests. The nurse will need to document the findings. It is most important to obtain the culture. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.8: Apply critical thinking in selected simulations related to physical assessment of the female reproductive system.

Question 30 Type: MCSA The nurse is caring for an adolescent female client who has come to the clinic for an annual physical examination. Which of the following questions would be best included in the data collection? 1. “Do you have a boyfriend?” 2. “Do you need birth control?” 3. “Are you attracted to boys?” 4. “Are you sexually active at this time?” Correct Answer: 4 Rationale 1: The nurse should ask questions in a manner to place the client at ease. The questions should ideally be gender neutral. Asking specifically about boys may limit the client’s response. Rationale 2: It is more important to find out about the sexual activity than the birth control initially. A guided discussion may eventually lead to asking these questions. Rationale 3: The nurse should ask questions in a manner to place the client at ease. The questions should ideally be gender neutral. Asking about the attraction to the opposite sex may appear judgmental to the client. Rationale 4: It is more important to find out about the sexual activity than the birth control initially. Global Rationale: The nurse should ask questions in a manner to place the client at ease. The questions should ideally be gender neutral. Asking specifically about boys may limit the client’s response. It is more important to find out about the sexual activity than the birth control initially. Clients may feel they do not need birth control Asking about the attraction to the opposite sex may appear judgmental to the client. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.8: Apply critical thinking in selected simulations related to physical assessment of the female reproductive system.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 23 Question 1 Type: MCSA The nurse is caring for a client with a right femur fracture. The nurse would correctly identify the femur as which of the following bone types? 1. Short 2. Long 3. Flat 4. Irregular Correct Answer: 2 Rationale 1: Bones are classified according to shape and composition. Short bones include the carpals and tarsals. Rationale 2: Bones are classified according to shape and composition. Long bones include the femur and humerus. Rationale 3: Bones are classified according to shape and composition. Flat bones include the parietal skull bone and sternum. Rationale 4: Bones are classified according to shape and composition. Irregular bonea include the vertebrae and hips. Global Rationale: Bones are classified according to shape and composition. Long bones include the femur and humerus; short bones include the carpals and tarsals; flat bones include the parietal skull bone and sternum; and irregular bones include the vertebrae and hips. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.1: Describe the anatomy and physiology of the bones, muscles, and joints. Question 2 Type: MCMA The client is recovering from orthopedic surgery on a fractured arm. The nurse realizes that skeletal muscles provide which of the following functions? Standard Text: Select all that apply.

1. Provide a body framework 2. Provide movement 3. Maintain posture 4. Generate heat 5. Calcium storage Correct Answer: 2,3,4 Rationale 1: Provide a body framework. Skeletal muscles provide movement, maintain posture, and generate heat. Skeletal muscles do not provide a framework for the body. The bones of the skeleton provide a framework and store minerals such as calcium and phosphorus. Rationale 2: Provide movement. Skeletal muscles provide movement, maintain posture, and generate heat. Rationale 3: Maintain posture. Skeletal muscles provide movement, maintain posture, and generate heat. Rationale 4: Generate heat. Skeletal muscles provide movement, maintain posture, and generate heat. Rationale 5: Calcium storage. Skeletal muscles do not provide a framework for the body nor do they store minerals such as calcium. The bones of the skeleton provide a framework and store minerals such as calcium and phosphorus. Global Rationale: Skeletal muscles provide movement, maintain posture, and generate heat. Skeletal muscles do not provide a framework for the body nor do they store minerals such as calcium. The bones of the skeleton provide a framework and store minerals such as calcium and phosphorus. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.1: Describe the anatomy and physiology of the bones, muscles, and joints. Question 3 Type: MCSA 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. Flat foot 2. Gouty arthritis 3. Hammertoe

4. Bunion Correct Answer: 4 Rationale 1: In pes planus, or flat foot, the arch of the foot is flattened, sometimes coming in contact with the floor. Rationale 2: The toes are common sites for gouty arthritis. In this condition the metarsolphlangeal joint of the toe is swollen, hot, red, and extremely painful. There is no deviation of the toes. Rationale 3: Hammertoe produces flexion of the proximal interphalangeal joint of a toe. The distal metarsophalalgeal joint hyperextends. Rationale 4: A hallux valgus, or bunion, causes a deviation of the great toe from the midline, and crowding of the remaining toes. This crowding results in deviation. The metatarsophalangeal joint and bursa become enlarged and inflamed. Global Rationale: A hallux valgus, or bunion, causes a deviation of the great toe from the midline, and crowding of the remaining toes. The metatarsophalangeal joint and bursa become enlarged and inflamed. In pes planus, or flat foot, the arch of the foot is flattened, sometimes coming in contact with the floor. Hammertoe produces flexion of the proximal interphalangeal joint of a toe, while the distal metatarsophalalgeal joint hyperextends. In gouty arthritis the metatarsophalangeal joint of the great toe is swollen, hot, red, and extremely painful. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.2: Discuss the directional movements of the joints. Question 4 Type: MCSA The nurse asks the client to pull the toes up towards the nose during an examination of the lower extremities. The nurse is assessing which of the following movements? 1. Inversion 2. Plantar flexion 3. Eversion 4. Dorsiflexion Correct Answer: 4 Rationale 1: Inversion is the movement of pointing the sole of the foot inward. Rationale 2: Plantar flexion is the movement of pointing the toes toward the floor.

Rationale 3: Eversion is the movement of pointing the sold of the food outward. Rationale 4: Dorsiflexion is the moement of pulling the toes upward toward the nose. Global Rationale: Dorsiflexion is the movement of pulling the toes upward toward the nose. Plantar flexion is the movement of pointing the toes toward the floor. Eversion is the movement of pointing the sole of the foot outward. Inversion is the movement of pointing the sole of the foot inward. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.2: Discuss the directional movements of the joints. Question 5 Type: MCMA 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? Standard Text: Select all that apply. 1. “Tilt your head back and look at the ceiling.” 2. “Lean your head to the side and attempt to touch your ear to your shoulder.” 3. “Touch your chin to your chest.” 4. “Attempt to raise your shoulders up toward your ears.” 5. “Attempt to rotate your head in a circular manner.” Correct Answer: 1,3,4,5 Rationale 1: “Tile your head back and look at the ceiling.” Tilting the head back and looking toward the ceiling is an example of hyperflexion. Rationale 2: “Lean your head to the side and attempt to touch your ear to your shoulder.” Lateral flexion can be assessed by tilting the head to each shoulder with the ear from the same side. Rationale 3: “Touch your chin to your chest.” Flexion refers to movements that reduce the angle. Touching the chin to the chest would be an example of flexion. Rationale 4: “Attempt to raise your shoulders up toward your ears.” Flexibility and mobility may be assessed by asking the client to raise and lower the shoulders but are not examples of methods to assess lateral flexion. Rationale 5: “Attempt to rotate your head in a circular manner.” Flexibility and mobility may be assessed by asking the client to rotate the head but it is not an example of methods of lateral flexion.

Global Rationale: Lateral flexion of the head is attempted by touching each shoulder of the ear on the same side. Tilting the head back to look at the ceiling would be an example of hyperflexion. Touching the chin to the chest would assess flexion. Raising the shoulders toward the ears and rotating the head are methods to assess mobility and flexibility of the client but do not demonstrate lateral flexion. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.2: Discuss the directional movements of the joints. Question 6 Type: MCSA The nurse is caring for a client with a knee injury. The nurse would correctly identify the knee as which of the following joint types? 1. Saddle 2. Hinge 3. Pivot 4. Plane Correct Answer: 2 Rationale 1: Saddle joints consist of an articulating bone having both concave and convex areas (resembling a saddle). The opposing surfaces fit together. The carpometacarpal joints of the thumbs are an example. Rationale 2: In hinge joints, a convex projection of one bone fits into a concave depression in another. Motion is similar to that of a mechanical hinge. These joints permit flexion and extension only. Examples include the elbow and knee joints. Rationale 3: In pivot joints, the rounded end of one bone protrudes into a ring of bone (and possibly ligaments). The only movement allowed is rotation of the bone around its own long axis or against the other bone. An example is the joint between the atlas and axis of the neck. Rationale 4: In plane joints, the articular surfaces are flat, allowing only slipping or gliding movements. Examples include the intercarpal and intertarsal joints, and the joints between the articular processes of the ribs. Global Rationale: The knee and elbows are hinge joints; the thumbs are saddle joints; the neck is a pivot joint; the intercarpals and intertarsals are plane joints. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.2: Discuss the directional movements of the joints. Question 7 Type: MCHS The nurse is preparing to assess the posterior spine of a client. The nurse prepares to identify the iliac crest to determine symmetry. Identify the location of the iliac crest.

Correct Answer: Rationale : The iliac crests are used as landmarks on the posterior spine. They are used to assess for symmetry. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system. Question 8 Type: HOTSPOT The nurse is caring for a client with an injury to the arm. To check the client ability to move the nurse directs the client to pronate the hand. Indicate the side of the table that arm should be rotated towards.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : Pronation is a rotational movement of the radius around the ulna. It will result in the rotation of the hand and forearm so that the palm surface is facing downward to a posterior or inferior position. Global Rationale:

Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system. Question 9 Type: HOTSPOT The school nurse is providing an educational meeting with a group of teenaged girls. The nurse is discussing the assessment for scoliosis. Use the diagram below to shade the area of the spine that will be assessed for the condition.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : Scoliosis is a screening frequently completed on teenaged girls. Scoliosis is the abnormal curvature of the thoracic spine. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system. Question 10 Type: HOTSPOT The nurse is performing the bulge test on a client’s left knee. Circle the area in which the nurse will need to assess for bulges when applying pressure.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The bulge sign can be assessed to check for the presence of fluid. If fluid is present there will be a bulging on the medial side. To perform the test, assist the client to a supine position. Use firm pressure to stroke the medial aspect of the knee upward several times displacing any fluid. Next apply pressure to the lateral side of the knee while observing the medial side. In a normal test no fluid is present. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system. Question 11 Type: MCMA A client comes to the emergency department complaining of a painful injury to the right knee received while playing basketball. The nurse would include which of the following in the examination of this client? Standard Text: Select all that apply. 1. Inspection 2. Palpation

3. Bulge sign testing 4. Ballottement 5. Percussion Correct Answer: 1,2,3,4 Rationale 1: Inspection. The nurse would visually inspect the knee’s general appearance including the presence or redness, swelling and dislocation. The knee’s appearance would be contrasted with the unaffected knee. Rationale 2: Palpation. The area would be palpated for tenderness and warmth. Rationale 3: Bulge sign testing. The bulge sign test is used to detect the presence of small amounts of fluid (4 to 8 ml) in the suprapatellar bursa. The test involves placing the client in the supine position and then using firm pressure to stroke the medial aspect of the knee upward several times, displacing any fluid. As the pressure is applied to the lateral side of the knee the medial side is observed for bulging. Rationale 4: Ballottement. Ballottement is a technique used to detect fluid, or to examine or detect floating body structures. The nurse displaces body fluid and then palpates the return impact of the body structure. Rationale 5: Percussion. Percussion is the use of tapping actions by the examiner. This tapping elicits sounds that can be evaluated for tone and depth to detect the presence of abnormalities. Percussion is normally utilized to assess the lungs and abdominal cavity. It is not used to assess for knee injuries. Global Rationale: The assessment of a client presenting with an injury to the knee would include inspection, palpation, bulge sign testing, and ballottement. The nurse would visually inspect the knee’s general appearance, including the presence or redness, swelling and dislocation. The knee’s appearance would be contrasted with the unaffected knee. The area would be palpated for tenderness and warmth. Ballottement is a technique used to detect fluid, or to examine or detect floating body structures. The nurse displaces body fluid and then palpates the return impact of the body structure. The bulge sign test is used to detect the presence of small amounts of fluid (4 to 8 ml) in the suprapatellar bursa. The test involves placing the client in the supine position and then using firm pressure to stroke the medial aspect of the knee upward several times, displacing any fluid. As the pressure is applied to the lateral side of the knee the medial side is observed for bulging. Percussion is the use of tapping actions by the examiner. This tapping elicits sounds that can be evaluated for tone and depth to detect the presence of abnormalities. Percussion is normally utilized to assess the lungs and abdominal cavity. It is not used to assess for knee injuries. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system. Question 12 Type: MCSA

The nurse is preparing to assess a client’s spine for abnormalities. The nurse would ask the client to do which of the following steps to gather the most information with this assessment? 1. Sit down, then stand as the nurse looks from the front of the client. 2. Stand, bend back slowly, then to the right and left while the nurse looks from the back. 3. Bend over, stand tall, and stretch arms over the head. 4. Sit down, then lean forward and dangle the arms at the sides of the body. Correct Answer: 2 Rationale 1: The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry. Rationale 2: The spine should be visually inspected by viewing the back of the client. The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry. The spine should appear straight when viewed from the back. Rationale 3: Bending and stretching will not illicit the needed information about the spine. Range of motion and flexibility may be assessed by asking the client to bend over or stretch. Rationale 4: The spine is assessed by asking the client to stand. The nurse will then visually assess the client from the back. Global Rationale: The spine should be visually inspected by viewing the back of the client. The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry. The spine should appear straight when viewed from the back. The cervical and lumbar spine should appear concave, and the thoracic spine should appear convex. Range of motion and flexibility may be assessed by asking the client to bend over or stretch. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system. Question 13 Type: MCSA The client’s chief complaint is numbness and tingling in the hands when interviewed by the nurse. The client complains of numbness and tingling in the arms when bending the wrist downward and pressing the backs of the hands together. The nurse would suspect which of the following conditions in this situation? 1. Arthritis of the wrists 2. Carpal tunnel syndrome

3. Crepitus of the wrists 4. Dupuytren’s contracture Correct Answer: 2 Rationale 1: Arthritis typically causes pain and limitations in movement but not numbness and tingling. Rationale 2: Carpal tunnel is a condition caused by compression of the median nerve. The test described is called Phalen’s test, and when used on individuals with carpal tunnel syndrome, 80 percent experience pain, tingling, and numbness that radiates to the arm, shoulder, neck, or chest within 60 seconds. Another assessment for carpal tunnel syndrome is called Tinel’s sign, and is elicited by percussing lightly over the median nerve in each wrist. The test is positive if the client feels numbness, tingling, and pain along the median nerve. Rationale 3: Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions. Rationale 4: Dupuytren’s contracture involves inability to extend the fourth and fifth fingers but is a painless, inherited disorder. Global Rationale: Carpal tunnel is a condition caused by compression of the median nerve. The test described is called Phalen’s test, and when used on individuals with carpal tunnel syndrome, 80 percent experience pain, tingling, and numbness that radiates to the arm, shoulder, neck, or chest within 60 seconds. Another assessment for carpal tunnel syndrome is called Tinel’s sign, and is elicited by percussing lightly over the median nerve in each wrist. The test is positive if the client feels numbness, tingling, and pain along the median nerve. Arthritis typically causes pain and limitations in movement but not numbness and tingling. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions. Dupuytren’s contracture involves inability to extend the fourth and fifth fingers but is a painless, inherited disorder. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system. Question 14 Type: MCSA 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. Dupuytren’s contracture 2. Carpal tunnel syndrome 3. Bursitis

4. Osteoarthritis Correct Answer: 1 Rationale 1: Dupuytren’s contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder. Rationale 2: Carpal tunnel is a condition caused by compression of the median nerve. In carpal tunnel syndrome the client feels numbness, tingling, and pain in the hands and wrists. Rationale 3: Bursitis involves inflammation of the bursae. The condition is manifested by redness, warmth, swelling, and tenderness. Rationale 4: Osteoarthritis is the degeneration of the joints. The condition typically causes pain and limitations in movement, but not numbness and tingling. Global Rationale: Dupuytren’s contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder. Carpal tunnel is a condition caused by compression of the median nerve. In carpal tunnel syndrome the client feels numbness, tingling, and pain in the hands and wrists. Bursitis involves inflammation of the bursae. The condition is manifested by redness, warmth, swelling, and tenderness. Osteoarthritis is the degeneration of the joints. The condition typically causes pain and limitations in movement, but not numbness and tingling. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 15 Type: MCSA 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. Rheumatoid arthritis 2. Osteoarthritis 3. Ganglion 4. Carpal tunnel syndrome Correct Answer: 3 Rationale 1: Rheumatoid arthritis is an autoimmune disorder that presents with pain and tenderness in the joints. The condition may affect numerous joints. It is a systematic condition in which other body parts may be impacted in varying degrees.

Rationale 2: Osteoarthritis is a condition in which the joints degenerate. The potential causes may include obesity, trauma, and occupational stressors. Joint pain with use/exercise is the chief symptom of osteoarthritis. It is commonly seen in the hips, knees, and hands. Rationale 3: A ganglion is a painless, round, fluid-filled mass. It arises from the tendon sheaths on the dorsum of the wrist and hand. It may be painful. Rationale 4: Carpal tunnel syndrome results from compression of the median nerve. It may be associated with occupations requiring repetitive tasks and pregnancy. It may begin with numbness and tingling in the hands and fingers. Over time the condition may advance toward an inability to grasp objects. Global Rationale: The findings describe a ganglion, a painless, round, fluid-filled mass that arises from the tendon sheaths on the dorsum of the wrist and hand. Rheumatoid arthritis is an autoimmune disorder that presents with joint pain and tenderness. The joint regions may exhibit warmth and swelling. Osteoarthritis is a condition in which the joints degenerate. The condition manifests with joint pain and stiffness. Carpal tunnel syndrome results from compression of the median nerve. It manifests with discomfort in the wrist and potentially the reduction in the ability to grasp objects. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 16 Type: MCSA The nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened. The nurse would correctly document this finding as which of the following? 1. Subluxation 2. Grinding 3. Crepitation 4. Joint dislocation Correct Answer: 3 Rationale 1: Subluxation refers to a partial joint location. Rationale 2: Grinding sounds may be heard or felt with musculoskeletal disorders but it is not appropriate medical terminology. Rationale 3: Crepitation is the medical term used to describe the grating sounds a joint makes when the articulating surfaces have lost their cushioning cartilage.

Rationale 4: There is inadequate information to determine the joint is indeed dislocated. Global Rationale: It is important to use proper terminology when reporting findings. Crepitation is the proper term when a grating sound is present in a joint. Crepitation results when the joint articulating surfaces have lost their cartilage. Subluxation refers to a partial joint dislocation. There is inadequate information to determine if the joint is dislocated. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 17 Type: MCSA The client’s chief complaint is tenderness and stiffness in the wrist and elbow when interviewed by the nurse. The client reports the discomfort is worsened with activity. The nurse would suspect which of the following conditions in this situation? 1. Carpal tunnel syndrome 2. Osteoarthritis 3. Crepitus of the wrists 4. Dupuytren’s contracture Correct Answer: 2 Rationale 1: Carpal tunnel syndrome is caused by compression of the median nerve. Rationale 2: Arthritis typically causes pain and limitations in movement, but not numbness and tingling. Rationale 3: Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative joint disease, trauma, or inflammatory conditions. Rationale 4: Dupuytren’s contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder. Global Rationale: Osteoarthritis is also known as degenerative joint disease. It is associated with pain and stiffness of the joints. Carpal tunnel syndrome is caused by compression of the median nerve. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative joint disease, trauma, or inflammatory conditions. Dupuytren’s contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder. Cognitive Level: Analyzing Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 18 Type: MCSA 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. Poor 2. Normal 3. Fair 4. Good Correct Answer: 4 Rationale 1: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. A rating of poor, or a 1, would be the presence of palpable muscle contraction with no movement. Rationale 2: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. Rationale 3: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. A rating of fair, or a 3, would be full range of motion with gravity. Rationale 4: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. A rating of good, or a 4, would be full range of motion against gravity with moderate resistance. Global Rationale: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. A rating of poor, or a 1, would be the presence of palpable muscle contraction with no movement. A rating of good, or a 4, would be full range of motion against gravity with moderate resistance. A rating of fair, or a 3, would be full range of motion with gravity. A rating of poor, or a 2, would be full range of motion without gravity, or passive motion. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 19 Type: MCSA

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. Arthritis 2. Bursitis 3. Epicondylitis 4. Crepitus Correct Answer: 3 Rationale 1: Rheumatoid arthritis may result in nodules in the olecranon bursa or along the extensor surface of the ulna. Nodules are firm, nontender, and not attached to the overlying skin. Rationale 2: Bursitis is characterized by a painful, inflamed warm area. Rationale 3: Lateral epicondylitis, also called tennis elbow, results from constant, repetitive movements of the wrist and/or forearm. Pain occurs when the client attempts to extend the wrist against resistance. Medial epicondylitis, also called pitcher’s or golfer’s elbow, results from constant, repetitive flexion of wrist. Pain occurs when the client attempts to flex the wrist against resistance. Rationale 4: Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions. Global Rationale: Lateral epicondylitis, also called tennis elbow, results from constant, repetitive movements of the wrist and/or forearm. Pain occurs when the client attempts to extend the wrist against resistance. Medial epicondylitis, also called pitcher’s or golfer’s elbow, results from constant, repetitive flexion of wrist. Pain occurs when the client attempts to flex the wrist against resistance. Rheumatoid arthritis will typically produce nontender nodules along the extensor surface of the ulna. Bursitis is characterized by a painful area of inflammation. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 20 Type: MCSA The nurse notes an exaggerated lumbar curve while inspecting the spine of a client. The nurse would correctly document which of the following choices? 1. Lordosis

2. Scoliosis 3. Kyphosis 4. Flattened curve Correct Answer: 1 Rationale 1: Lordosis is an exaggerated lumbar curve and is often present in pregnancy, obesity, or other skeletal changes. The spine leans to the left or right in a list, and a line drawn from the thoracic one vertebrae does not fall between the gluteal cleft. Rationale 2: Scoliosis results when the spine curves to the right or left. It is noted in the thoracic region. Rationale 3: Kyphosis is an exaggerated thoracic dorsal curve resulting in asymmetry between the sides of the posterior thorax. Rationale 4: A flattened lumbar curve is a concave curvature of the lumbar areas and occurs when lumbar muscles spasm. Global Rationale: Lordosis is an exaggerated lumbar curve and is often present in pregnancy, obesity, or other skeletal changes. The spine leans to the left or right in a list, and a line drawn from the thoracic one vertebrae does not fall between the gluteal cleft. Scoliosis results when the spine curves to the right or left. It is noted in the thoracic region. Kyphosis is an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. A flattened lumbar curve is a concave curvature of the lumbar areas and occurs when lumbar muscles spasm. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 21 Type: MCSA The nurse notes asymmetry of the iliac crests and gluteal folds while inspecting the spine of a client. The client’s spine has a slight curvature to the right, but denies complaints of pain. The nurse would correctly document which of the following choices? 1. Kyphosis 2. Scoliosis 3. Spinal list 4. Lordosis

Correct Answer: 2 Rationale 1: Kyphosis results in an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. Rationale 2: Scoliosis results when the spine curves to the right or left, causing an exaggerated thoracic convexity on that side. Rationale 3: A spinal list occurs when the spine leans to the left or right. The condition may be noted in conditions with paravertebral muscle spasms or herniated disks. Rationale 4: Lordosis is an exaggerated curve of the lumbar spine. It is noted most in condition such as pregnancy and obesity. Global Rationale: In scoliosis the spine curves to the right or left, causing an exaggerated thoracic convexity on that side. Kyphosis results in an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. The spine leans to the left or right in a spinal list. A plumb line drawn from T1 does not fall between the gluteal cleft. This condition may occur with spasms in the paravertebral muscles or a herniated disk. Lordosis refers to an exaggerated curve of the lumbar spine. It is seen most commonly in conditions such as pregnancy and obesity. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 22 Type: MCSA 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. Bunion 2. Synovitis 3. Hammertoe 4. Gout Correct Answer: 4 Rationale 1: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. Bunions are thickening and inflammation of the bursa of the joint of the great toe.

Rationale 2: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. Synovitis refers to an inflammation of the synovial membrane. It may be present with pain and swelling but is typically seen more in the knee. Rationale 3: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. In hammertoe the metatarsophalangeal joint of the toe hyperextends with flexion of the interphalangeal joint of the toe. Rationale 4: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. Global Rationale: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. Bunions are thickening and inflammation of the bursa of the joint of the great toe. Synovitis occurs in the knee. In hammertoe the metatarsophalangeal joint of the toe hyperextends with flexion of the interphalangeal joint of the toe. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 23 Type: MCMA The nurse is assessing a client with suspected rheumatoid arthritis. Which of the following musculoskeletal changes would contribute to a positive diagnosis? Standard Text: Select all that apply. 1. Ulnar deviation 2. Bouchard’s nodes 3. Heberden’s nodes 4. Swan-neck deformity 5. Symmetrical loss of function in extremities Correct Answer: 1,4,5 Rationale 1: Ulnar deviation. In rheumatoid arthritis there is chronic inflammation of the metacarpophalangeal and interphalangeal joints leading to ulnar deviation.

Rationale 2: Bouchard’s nodes. The nodes that may appear on the fingers such as Bouchard’s and Heberden’s nodes are associated with osteoarthritis. Bouchards nodes are located on the proximal interphalangeal joints. Rationale 3: Heberden’s nodes. The nodes that may appear on the fingers such as Bouchard’s and Heberden’s nodes are associated with osteoarthritis. Heberden’s nodes are hard, typically painless, bony enlargements associated with osteoarthritis that may occur in the distal interphalangeal joints. Rationale 4: Swan-neck deformity. Another manifestation of rheumatoid arthritis involves what are known as swan-neck contractures. These result when the proximal interphalangeal joints are hyperextended while the distal interphalangeal joints are fixed in flexion. Rationale 5: Symmetrical loss of function in extremities. Rheumatoid arthritis impacts the extremities symmetrically. Global Rationale: Rheumatoid arthritis is an autoimmune condition. The disease may impact multiple body systems. Symptoms of the condition include pain and inflammation. In rheumatoid arthritis there is chronic inflammation of the metacarpophalangeal and interphalangeal joints leading to ulnar deviation. Another manifestation of rheumatoid arthritis involves what are known as swan-neck contractures. These result when the proximal interphalangeal joints are hyperextended while the distal interphalangeal joints are fixed in flexion. The impact on the extremities is typically symmetrical in rheumatoid arthritis. The nodes that may appear on the fingers such as Bouchard’s and Heberden’s nodes are associated with osteoarthritis. Osteoarthritis is a condition of joint degeneration. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 24 Type: MCSA The nurse is assessing a client with a suspected femur fracture. Which of the following findings would most support this diagnosis? 1. External rotation of the lower leg and foot 2. Internal rotation of the lower leg and foot 3. Limited hip internal rotation 4. Limited hip external rotation Correct Answer: 1 Rationale 1: External rotation, not internal rotation, of the lower leg and foot is a classic sign of a fractured femur.

Rationale 2: External rotation, not internal rotation, of the lower leg and foot is a classic sign of a fractured femur. Rationale 3: Limitations of internal and external rotation in the hip signify inflammatory or degenerative joint diseases. Rationale 4: Limitations of internal and external rotation in the hip signify inflammatory or degenerative joint diseases. Global Rationale: External rotation, not internal rotation, of the lower leg and foot is a classic sign of a fractured femur. Limitations of internal and external rotation in the hip signify inflammatory or degenerative joint diseases. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system. Question 25 Type: MCSA The nurse notes a child sitting in reverse tailor position during a well-child examination. The nurse would correctly choose which of the following actions in this situation? 1. Notify the healthcare provider so that X-rays can be obtained. 2. Explain to the parent that this can cause joint stress. 3. Continue with the examination. 4. Assess the child for back problems. Correct Answer: 2 Rationale 1: The reverse tailor position should be discouraged as a result of the stresses it places on the joints of a growing child. The preferred sitting position of the child does not, however, indicate the presence of deformities that would require diagnostic testing. Rationale 2: The reverse tailor position stresses the hip, knee, and ankle joints of the growing child. Children should be encouraged to try other sitting positions to prevent these problems, and teaching the parent and the child regarding this is best done at the time the position is noted. Rationale 3: The reverse tailor position places stress on the joints of the growing child. The best time for the nurse to provide education is at the time of discovery. This education should be performed prior to completing of the full assessment. Rationale 4: The reverse tailor position stresses the hip, knee, and ankle joints of the growing child. Back problems are not directly associated with the reverse tailor position.

Global Rationale: The reverse tailor position stresses the hip, knee, and ankle joints of the growing child. The position has the individual sitting flat on the floor with the legs bent back similar to an “upside down W.” Children should be encouraged to try other sitting positions to prevent these problems, and teaching the parent and the child regarding this is best done at the time the position is noted. There is no need for the nurse to anticipate that X-rays will be needed as this position does not indicate deformities requiring diagnostic tests. The examination is a period of time in which the nurse can provide teaching to the patient. It would be remiss to discuss this potential problem with the parents at the time noted. Thus, continuation of the examination should not be done before the education has taken place. The reverse tailor position does not promote back problems for the child. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental related variations in assessment and findings. Question 26 Type: MCSA A 38-week pregnant client is complaining of lower back pain. The nurse notes a slight lordosis and waddling gait in the client. The nurse would correctly choose which of the following actions in this situation? 1. Suggest the client begin bed rest. 2. Notify the healthcare provider of the findings. 3. Document the findings as normal. 4. Ask the client if she has been lifting. Correct Answer: 3 Rationale 1: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The woman’s center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the later stages of pregnancy and do not require bed rest. Rationale 2: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The woman’s center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the later stages of pregnancy and do not require notification of the healthcare provider. Rationale 3: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The woman’s center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the later stages of pregnancy. The nurse should document these findings as normal.

Rationale 4: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The woman’s center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the late stages of pregnancy and are not the result of lifting. Global Rationale: During pregnancy estrogen and other hormones soften the cartilage in the pelvis and increase the mobility of the joints. Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The woman’s center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the late stages of pregnancy and do not require bed rest or notification of the healthcare provider. Lordosis and waddling gait in the later stages of pregnancy are not the result of lifting. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental related variations in assessment and findings. Question 27 Type: MCSA The nurse is caring for an elderly client. The nurse would expect which of the following in the musculoskeletal system of an older adult? 1. Difficulty with dexterity 2. Increased bone production 3. Risk for fractures 4. Pain when ambulating Correct Answer: 3 Rationale 1: Difficulty with dexterity is a direct change associated with aging. Older clients may have chronic conditions that may indirectly cause changes in this skill. Rationale 2: The rate of bone production does not increase with aging. Rationale 3: Elderly clients are at risk for fracture as a result of decreased calcium absorption and loss of bone density. Rationale 4: Pain with ambulation is not a direct result of aging. Some chronic conditions seen with greater frequency in the older adult may be associated with painful ambulation. Global Rationale: Elderly clients are at risk for fractures due to decreased calcium absorption and loss of bone density. Difficulty with dexterity is not a normal age related change. The rate of bone production is not increased

but decreased with aging. Pain with ambulation is not a direct result of aging; however, some chronic conditions of aging may be associated with varying levels and types of discomfort. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental related variations in assessment and findings. Question 28 Type: MCSA The nurse is caring for an elderly client. The nurse would expect which of the following bone to occur with aging? 1. No bone changes are associated with aging 2. Increased osteoblastic activity 3. Decreased calcium absorption 4. Increase in bone density Correct Answer: 3 Rationale 1: As individuals age, physiologic changes take place in the bones, muscles, connective tissue, and joints. These changes may affect the older client’s mobility and endurance. Bone changes include decreased calcium absorption and reduced osteoblast production. Rationale 2: Bone changes associated with aging include reduced osteoblast production. Osteoblasts are the cells responsible for bone production. Rationale 3: The rate of calcium absorption is reduced with aging. Rationale 4: Reductions in calcium absorption and reduced osteoblast production will result in a reduction of bone density. These changes are associated with aging. Global Rationale: As individuals age, physiologic changes take place in the bones, muscles, connective tissue, and joints. These changes may affect the older client’s mobility and endurance. Bone changes include decreased calcium absorption and reduced osteoblast production. Elderly persons who are housebound and immobile or whose dietary intake of calcium and vitamin D is low may also experience reduced bone mass and strength. During aging, bone resorption occurs more rapidly than new bone growth, resulting in the loss of bone density typical of osteoporosis. The entire skeleton is affected, but the vertebrae and long bones are especially impacted. The elderly client will experience decreased calcium absorption. Osteoblasts are the cells responsible for bone production. Osteoblast activity is reduced, not increased, with aging. Bone density decreases, not increases, in the elderly.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental related variations in assessment and findings. Question 29 Type: MCSA 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 a program to address available medication therapies for the individual with osteoporosis. 2. Community screening programs to identify individuals who have early onset osteoporosis. 3. Community education programs to discuss methods that can be implemented to reduce the chance of developing osteoporosis. 4. The development of community support programs for individuals who have been diagnosed with osteoporosis. Correct Answer: 3 Rationale 1: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary prevention’s goal is to manage existing conditions while seeking to prevent related complications. Programs seeking to discuss treatment options or to offer support for clients with the disorder are examples of tertiary prevention. Rationale 2: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary prevention’s goal is to manage existing conditions while seeking to prevent related complications. Secondary prevention seeks to promote early diagnosis of conditions. Rationale 3: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary prevention’s goal is to manage existing conditions while seeking to prevent related complications. Programs to reduce the incidence of osteoporosis are an example of primary prevention. Rationale 4: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary prevention’s goal is to manage existing conditions while seeking to prevent related complications. Programs seeking to discuss treatment options or to offer support for clients with the disorder are examples of tertiary prevention. Global Rationale: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary prevention’s goal is to manage existing conditions while seeking to prevent related complications. Programs to reduce the incidence of osteoporosis are an example of primary prevention. Secondary prevention activities would include screening programs to identify

individuals with early onset osteoporosis. Programs seeking to discuss treatment options or to offer support for clients with the disorder are examples of tertiary prevention. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.7: Discuss objectives related to overall health of the musculoskeletal system as presented in Healthy People 2020. Question 30 Type: MCSA 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. “You have a muscle tear at the shoulder.” 3. “Your shoulder bone has come apart from the shoulder joint.” 4. “Your shoulder is fractured and separated from the joint.” Correct Answer: 3 Rationale 1: The client has voiced a concern and asked a question of the nurse. It is within the scope of practice and responsibility of the nurse to respond to this inquiry. Rationale 2: A dislocation is a displacement of the bone from its usual anatomical location in the joint. A muscle tear is not the same thing as a dislocation. Rationale 3: A dislocation is a displacement of the bone from its usual anatomical location in the joint. Rationale 4: A dislocation is displacement of the bone from its usual anatomical location. This condition does not include a fracture. Global Rationale: Dislocation is a displacement of the bone from its usual anatomical location in the joint. A dislocation is not the same as a muscle tear, or a fracture of the shoulder. The client has a concern and the nurse has the obligation to attempt to answer the questions presented within the nurse’s scope of practice and responsibility. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.8: Apply critical thinking in selected simulations related to physical assessment of the musculoskeletal system. Question 31 Type: MCMA The nurse is discharging a client with osteoarthritis. Which of the following would the nurse include in the teaching plan? Standard Text: Select all that apply. 1. Obesity increases the risks of bone, muscle, and joint disorders. 2. Musculoskeletal health is influenced by the diet. 3. Exercise is important in the prevention of osteoarthritis. 4. Smoking and alcohol contribute to the development of osteoarthritis. 5. As the condition progresses the hands may develop contractures that resemble swan necks Correct Answer: 1,2,3 Rationale 1: Obesity increases the risks of bone, muscle, and joint disorders. Obesity places an increase in stress on the bones and joints. Obesity is viewed as a risk factor for the development of osteoarthritis. Rationale 2: Musculoskeletal health is influenced by the diet. Dietary intake has an impact on musculoskeletal health. Vitamin D and calcium are associated with bone health. Protein intake is associated with healthy muscles. Rationale 3: Exercise is important in the prevention of osteoarthritis. Exercise increases muscle strength and flexibility. Rationale 4: Smoking and alcohol contribute to the development of osteoarthritis. Smoking and alcohol are risk factors for the development of osteoporosis not osteoarthritis. Rationale 5: As the condition progresses the hands may develop contractures that resemble swan necks. Swan-neck contractures are a deformity noted in the hand of an individual diagnosed with rheumatoid arthritis. Rheumatoid arthritis is a systemic disorder of autoimmune origin. Global Rationale: Osteoarthritis is a condition that results from degeneration of the joints. Risk factors include aging, obesity, congenital abnormalities, and occupations that place excessive stress on the joints. Dietary intake has an impact on musculoskeletal health. Calcium and vitamin D both promote strong bones. Regular exercise will promote healthful musculoskeletal functioning. Exercise increases muscle strength and flexibility. Smoking and alcohol contribute to the development of osteoporosis, not osteoarthritis. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.8: Apply critical thinking in selected simulations related to physical assessment of the musculoskeletal system. Question 32 Type: MCSA The nursing student is planning to observe the registered nurse complete a focused interview on a client being admitted to the facility with complaints of leg pain. Which of the following statements by the student nurse indicates the need for further education? 1. “The focused interview will be guided by the physical assessment that was completed by the healthcare provider prior to admission.” 2. “Subjective information is contained in the focused assessment.” 3. “The age, gender, and past medical history of the client are used to guide the questions in the focused assessment.” 4. “A focus interview on the musculoskeletal system is individualized for each client.” Correct Answer: 1 Rationale 1: “The focused interview will be guided by the physical assessment that was completed by the healthcare provider prior to admission.” The focused interview is used to guide the physical assessment on the client. Rationale 2: “Subjective information is contained in the focused assessment.” The information obtained by the focused interview is subjective. Subjective data refers to that information that is obtained from the client and family. Rationale 3: “The age, gender, and past medical history of the client are used to guide the questions in the focused assessment.” The nurse will consider the client’s age, gender, race, culture, past and current medical history to guide the interview questions thus making the interview individualized. Rationale 4: “A focus interview on the musculoskeletal system is individualized for each client.” The nurse will consider the client’s age, gender, race, culture, past and current medical history to guide the interview questions thus making the interview individualized. Global Rationale: The focused interview is used to guide the physical assessment on the client. The information obtained in the focused interview is subjective. The nurse will consider the client’s age, gender, race, culture, past and current medical history to guide the interview questions thus making the interview individualized. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.3: Develop questions to be used when completing the focused interview.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 24 Question 1 Type: MCMA The student nurse is reviewing the cranial nerves. The student recognizes some of the nerves are exclusively sensory nerves. Which of the following cranial nerves belong to this group? Standard Text: Select all that apply. 1. Olfactory nerve (cranial nerve I) 2. Optic nerve (cranial nerve II) 3. Trochlear nerve (cranial nerve IV) 4. Trigeminal nerve (cranial nerve V) 5. Facial nerve (cranial nerve VII) Correct Answer: 1,2 Rationale 1: Olfactory nerve (cranial cerve I). The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve responsible for vision. Rationale 2: Optic nerve (cranial nerve II). The cranial nerves may be classified by function. The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve responsible for vision. Rationale 3: Trochlear nerve (cranial nerve IV). The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The trochlear nerve is a motor nerve responsible for eye movement. Rationale 4: Trigeminal nerve (cranial nerve V). The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The trigeminal nerve is a mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity and palate. Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible. Rationale 5: Facial nerve (cranial nerve VI). The cranial nerves may be classified by function. The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow

the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The facial nerve is a mixed nerve responsible for taste, facial movements, and the production of tears and salivary stimulation. Global Rationale: The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve responsible for vision. The trochlear nerve is a motor nerve responsible for eye movement. The trigeminal nerve is a mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity, and palate. Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible. The facial nerve is a mixed nerve responsible for taste, facial movements, and the production of tears and salivary stimulation. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system. Question 2 Type: HOTSPOT The nurse is caring for a client having problems with emotional appropriateness as a result of a brain injury. Mark the area that has most likely been damaged.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The frontal lobe of the cerebrum is responsible for the control of emotions.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system. Question 3 Type: HOTSPOT 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?

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The brain stem is responsible for control of the vital signs. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system. Question 4 Type: MCSA

The nurse is assessing a client to determine tremors associated with Parkinson’s disease. The nurse would correctly observe for which of the following movements? 1. Fasciculations 2. Chorea 3. Rhythmic shaking 4. Athetoid movements Correct Answer: 3 Rationale 1: Fasciculations are muscle twitches. Rationale 2: Chores refer to controllable jerking movements as are associated with Huntington’s disease. Rationale 3: Rhythmic shaking of the hands is a manifestations associated with Parkinson’s disease. Rationale 4: Athetoid moements are repetitive and slow and are seen with cerebral palsy. Global Rationale: The tremors noted with Parkinson’s disease produce rhythmic shaking of the hands. Fasciculations are muscle twitches; chorea is the uncontrollable jerking associated with Huntington’s disease; athetoid movements are repetitive and slow and are seen with cerebral palsy. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system. Question 5 Type: MCSA The nurse is performing a neurological assessment on a client experiencing anosmia. The nurse would suspect cranial nerve involvement in which of the following? 1. Trochlear (cranial nerve IV) 2. Trigeminal (cranial nerve V) 3. Olfactory (cranial nerve I) 4. Oculomotor (cranial nerve III) Correct Answer: 3

Rationale 1: The trochlear nerve (cranial nerve IV) is related to vision. Dysfunction of the trochlear nerve nerve may include diplopia or strabismus. Rationale 2: The trigeminal nerve (cranial nerve V) is responsible for sensory impulses from scalp, upper eyelid, nose, cornea, and lacrimal gland. Dysfunction of the trigeminal nerve may be associated with a loss of facial sensation. Rationale 3: Anosmia is the absence of the sense of smell and can be indicative of problems with the olfactory nerve (cranial nerve I). Rationale 4: The oculomotor nerve (cranial nerve III) is associated with vision. Global Rationale: Anosmia is the absence of the sense of smell and can be indicative of problems with the olfactory nerve (cranial nerve I). The trochlear nerve (cranial nerve IV) is responsible for eye muscle movements. Dysfunction of the trochlear nerve nerve may include diplopia or strabismus. The trigeminal nerve (cranial nerve V) has three branches. The ophthalmic branch is responsible for sensory impulses from scalp, upper eyelid, nose, cornea, and lacrimal gland. The maxillary branch is responsible for sensory impulses from lower eyelid, nasal cavity, upper teeth, upper lip, and palate. The mandibular branch controls sensory impulses from the tongue, lower teeth, skin of chin, and lower lip. Motor action function includes teeth clenching, movements. Dysfunction of the trigeminal nerve may be associated with a loss of facial sensation, sensation deficits in the tongue, lower teeth, skin of the chin and lower lip, and an inability to clench the teeth. The oculomotor nerve (cranial nerve III) is associated with papillary reflexes and extrinsic muscle movements of the eyes. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system. Question 6 Type: MCSA The nurse is assessing the patellar reflex on a client and obtains no reflexive activity. The client is alert and oriented. The nurse should do which of the following in this situation? 1. Document the findings as normal. 2. Notify the healthcare provider immediately. 3. Look at the medication records for central nervous system depressants. 4. Retest the reflex after having the client use distraction during the exam. Correct Answer: 4 Rationale 1: Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation

at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated. The client should be encouraged to relax. It may be necessary to distract the client to achieve relaxation of the muscle before striking the tendon. Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated. Rationale 2: There is no immediate need to notify the healthcare provider. Rationale 3: Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated. Medications should eventually be reviewed to determine any impact on the nervous system but this action does not precede attempting to reassess the reflexes. Rationale 4: Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated. The client should be encouraged to relax. Global Rationale: Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated. The client should be encouraged to relax. It may be necessary to distract the client to achieve relaxation of the muscle before striking the tendon. Documentation of the reflexes as normal is not appropriate, as a score of 0 is not normal. There is no immediate need to notify the healthcare provider. Medications should eventually be reviewed to determine any impact on the nervous system but this action does not precede attempting to reassess the reflexes. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system. Question 7 Type: MCSA The nurse is interviewing a client with suspected Lyme disease. Which of the following questions would be a priority in this situation?

1. “When was your last seizure?” 2. “Have you been hiking or camping lately?” 3. “What has your temperature been running?” 4. “Do you have an appetite?” Correct Answer: 2 Rationale 1: Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. Lyme disease if not treated may result in neurological disorders. There is not, however, any indication that the client has long-term Lyme disease or neurological changes. Rationale 2: Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. Rationale 3: Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. During the initial period after becoming infected the client may experience flu-like illnesses but there is no indication that this is the primary concern for the client. Rationale 4: Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. An infectious process may result in changes in the client’s appetite or dietary but this is not the priority area of concern for investigation. Global Rationale: Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. Lyme disease if not treated may result in neurological disorders. There is not, however, any indication that the client has long-term Lyme disease or neurological changes. During the initial period after becoming infected the client may experience flu-like illnesses but there is no indication that this is the primary concern for the client. While appetite changes may result during an infection this is not the priority for the nurse’s questions. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2: Develop questions to be used when completing the focused interview. Question 8 Type: MCSA The nurse is performing the Romberg test and asks the client to stand with the feet together and eyes closed. The nurse notes the findings are normal. Which of the following client responses occurred in this situation? The client: 1. Swayed from side to side.

2. Had minimal swaying. 3. Felt moderately dizzy. 4. Had complete loss of balance. Correct Answer: 2 Rationale 1: The Romberg test is used to test coordination and equilibrium. A minimal amount of swaying is normal. Swaying from side to side is not a normal finding. Rationale 2: The Romberg test is used to test coordination and equilibrium. A minimal amount of swaying is normal. Rationale 3: The Romberg test is used to test coordination and equilibrium. During the test, the client is asked to stand with feet together and arms at the sides. A minimal amount of swaying is normal. The onset of dizziness is not a normal finding. Rationale 4: The Romberg test is used to test coordination and equilibrium. A minimal amount of swaying is normal. A complete loss of balance is not a normal finding. Global Rationale: The Romberg test is used to test coordination and equilibrium. During the test, the client is asked to stand with feet together and arms at the sides. The client’s eyes are initially open. Then, the examiner will ask the client to close his eyes. The examiner will need to observe for swaying. A minimal amount of swaying is normal. Dizziness during the test is not a normal finding. Significant swaying from side to side and loss of balance are not normal findings and may indicate a cerebellar dysfunction. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system. Question 9 Type: MCMA 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? Standard Text: Select all that apply. 1. No response with eyes with commands 2. No verbal response 3. Pupil response sluggish 4. No motor movement

5. Pupils fixed and dilated Correct Answer: 1,2,4 Rationale 1: No response with eyes with commands. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. Rationale 2: No verbal response. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. Rationale 3: Pupil response sluggish. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. The lower the score, the more critical the client’s condition. A score of 3 indicates the client’s condition is grave. Pupil activity is not evaluated using the Glascow Coma Scale. Rationale 4: No motor movement. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. The lower the score, the more critical the client’s condition. A score of 3 indicates the client’s condition is grave. Rationale 5: Pupils fixed and dilated. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. The lower the score, the more critical the client’s condition. A score of 3 indicates the client’s condition is grave. Pupil activity is not evaluated using the Glascow Coma Scale. Global Rationale: The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response and motor response indicate a score of 3 points. Lower scores indicate more critical conditions. A score of 3 indicates the client’s condition is grave. Pupil activity is not evaluated using the Glascow Coma Scale. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system. Question 10 Type: MCSA The nurse is performing a neurological assessment and needs to test cranial nerves. The nurse asks the client to close both eyes and report when a touch with a wisp of cotton is felt. The nurse is assessing the function of which of the following cranial nerves?

1. Trigeminal nerve (cranial nerve V) 2. Abducens nerve (cranial nerve VI) 3. Facial nerve (cranial nerve VII) 4. Optic nerve (cranial nerve II) Correct Answer: 1 Rationale 1: The cranial nerve V is responsible for facial sensations and may be assessed by a wisp of cotton on the face. Rationale 2: The cranial nerve VI is related to vision. Rationale 3: The cranial nerve VII is related to facial movements and the sensation of taste. Rationale 4: The cranial nerve II is related to vision. Global Rationale: The trigeminal nerve, cranial nerve V, is responsible for the facial sensations, sensory impulses from the tongue, lower teeth, skin of chin, and lower lip. The nerve also has motor functions including teeth clenching and movement of the mandible. The abducens nerve, cranial nerve VI, is related to vision. The facial nerve, cranial nerve VII, has responsibilities including facial expressions, the production of tears and salivary stimulation and is also associated with taste. The optic nerve, cranial nerve II, has the sensory function of vision. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system. Question 11 Type: MCSA The nurse in the photograph is performing an assessment on which of the following cranial nerves?

1. Olfactory nerve (cranial nerve I) 2. Optic nerve (cranial nerve II) 3. Oculomotor nerve (cranial nerve III) 4. Trochlear nerve (cranial nerve IV) Correct Answer: 1 Rationale 1: The sense of smell assessment is being demonstrated in the photograph. The olfactory nerve (cranial nerve I) is being evaluated. Rationale 2: Cranial nerve II is the optic nerve. Assessment of cranial nerve II (optic nerve) would involve assessment of vision. Rationale 3: Cranial nerve III (oculomotor nerve) involves the assessment of vision-related parameters. Rationale 4: Cranial nerve IV (trochlear nerve) involves the assessment of vision related parameters. Global Rationale: The sense of smell assessment is being demonstrated in the photograph. The olfactory nerve (cranial nerve I), which is responsible for the sense of smell, is being evaluated. Cranial nerve II is the optic nerve. Assessment of cranial nerve II (optic nerve) would involve assessment of vision. Cranial nerve III (oculomotor nerve) involves the assessment of papillary reactivity and the extrinsic muscles of the eyes. Cranial nerve IV

(trochlear nerve) assessment would require assessing the movements of the eyes. This would include instructing the client to follow an object such as the examiner’s finger with the eyes. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system. Question 12 Type: MCSA Review the 2 photographs below. Which of the following cranial nerves is being evaluated by this activity being demonstrated?

1. Trigeminal nerve (cranial nerve V) 2. Facial nerve (cranial nerve VII) 3. Vagus nerve (cranial nerve X) 4. Hypoglossal nerve (cranial nerve XII) Correct Answer: 4 Rationale 1: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing, movement of food during eating, chewing and speech. The trigeminal nerve (cranial nerve V) is responsible for sensory impulses from the tongue, lower teeth, skin of the teeth and lower lip. Rationale 2: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing, movement of food during eating, chewing and speech. The facial nerve (cranial nerve VII) is responsible for the sense of taste.

Rationale 3: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing, movement of food during eating, chewing and speech. The vagus nerve (cranial nerve X) innervates the muscles of the throat and mouth for swallowing and talking. Rationale 4: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing, movement of food during eating, chewing, and speech. Global Rationale: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing, movement of food during eating, chewing and speech. The trigeminal nerve (cranial nerve V) is responsible for facial sensation and temporal and massetter strength. The facial nerve (cranial nerve VII) is responsible for the sense of taste and facial expressions. The vagus nerve (cranial nerve X) innervates the muscles of the throat and mouth for swallowing and talking. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system. Question 13 Type: MCSA The nurse is examining a client experiencing vertigo and wants to perform the Romberg test. The nurse would correctly provide which set of instructions to the client? 1. “Touch your finger to your nose, alternating hands.” 2. “Walk across the room by placing one foot in front of the other, heel to toes.” 3. “Walk on your toes, then on your heels, then on your toes again.” 4. “Stand with your feet together, arms at sides, and eyes open.” Correct Answer: 4 Rationale 1: The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to stand with feet together, arms at sides, and eyes open. As the test progresses the client is asked to close her eyes. The amount of swaying done by the client once the eyes are closed is observed. Touching the finger to the nose with alternating hands is referred to as the finger-to-nose test and is used to assess coordination and equilibrium but is not the same as the Romberg test. Rationale 2: Walking across the room in this manner describes tandem walking. This technique is used to observe gait. Rationale 3: Walking in this manner enables the examiner to assess posture. The examiner should note the client’s stance and the degree of stiffness or relaxation.

Rationale 4: The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to close her eyes. The degree of swaying demonstrated is evaluated. Global Rationale: The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to stand with feet together, arms at sides, and eyes open. As the test progresses the client is asked to close her eyes. The amount of swaying done by the client once the eyes are closed is observed. Walking across the room by placing one foot in front of the other, heel to toes, describes tandem walking, which is used to observe gait. Posture is assessed by asking the client to walk on the toes, then on the heels. Touching the finger to the nose with alternating hands is referred to as the finger-to-nose test and is used to assess coordination and equilibrium but is not the same as the Romberg test. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system. Question 14 Type: MCSA The nurse is performing a neurological assessment on a client and needs to use stereognosis[0] Which of the following instructions would the nurse provide for the client? 1. “Tell me if you feel one or two objects touching you with your eyes closed.” 2. “Identify the object in your hand with your eyes closed.” 3. “Identify the number being traced in your hand with your eyes closed.” 4. “Open and close your hand each time I tell you to.” Correct Answer: 2 Rationale 1: Stereognosis is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. Asking the client to identify the presence of objects touching them is not an example of the technique. Rationale 2: Stereognosis is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. Rationale 3: Stereognosis is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. Asking the client to identify the presence of objects touching them is not an example of the technique. Graphesthesia is the ability to perceive writing on the skin. Rationale 4: Sterognosis is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. Asking the client to open and close the hand may be used to assess the ability to follow commands to assess hand strength.

Global Rationale: Stereognosis [0]is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. Asking the client to identify the presence of objects touching them is not an example of the technique. Graphesthesia is the ability to perceive writing on the skin. Asking the client to open and close the hand may be used to assess the ability to follow commands to assess hand strength. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system. Question 15 Type: MCSA The nurse performing reflex testing on a client uses the reflex hammer to gently strike the forearm about two inches above the wrist. The nurse is assessing which of the following reflexes? 1. Brachioradialis 2. Biceps 3. Triceps 4. Achilles Correct Answer: 1 Rationale 1: The brachioradialis reflex is initiated by striking the forearm just above the wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon. Rationale 2: The brachioradialis reflex is initiated by striking the forearm just above the wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon. Rationale 3: The brachioradialis reflex is initiated by striking the forearm just above the wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon. Rationale 4: The brachioradialis reflex is initiated by striking the forearm just above the wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon. Global Rationale: The brachioradialis reflex is initiated by striking the forearm just above the wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system. Question 16 Type: MCSA The nurse is admitting a client with suspected meningitis and notes a positive Brudzinski’s sign has been noted in the history and physical. To validate this assessment finding, the nurse would note which of the following? 1. Seizure activity 2. Neck pain and stiffness 3. Flexion of the legs and thighs 4. Neck extension Correct Answer: 3 Rationale 1: Brudzinski’s sign is assessed in clients suspected of having meningitis. To assess for this sign the client is placed in a supine position and assisted to flex the neck. In a positive test the legs and thighs will also flex. Seizure activity may be seen in meningitis but seizure activity does not constitute a positive Brudzinski’s sign. Rationale 2: Brudzinski’s sign is assessed in clients suspected of having meningitis. To assess for this sign the client is placed in a supine position and assisted to flex the neck. In a positive test the legs and thighs will also flex. Neck pain and stiffness may be noted with meningitis but this is referred to as nuchal rigidity. Rationale 3: Brudzinski’s sign is assessed in clients suspected of having meningitis. To assess for this sign the client is placed in a supine position and assisted to flex the neck. In a positive test the legs and thighs will also flex. Rationale 4: Neck extension is not associated with Brudzinski’s sign. Global Rationale: Brudzinski’s sign is assessed in clients suspected of having meningitis. To assess for this sign the client is placed in a supine position and assisted to flex the neck. In a positive test the legs and thighs will also flex. Seizure activity may be seen in meningitis but seizure activity does not constitute a positive Brudzinski’s sign. Neck pain and stiffness may be noted with meningitis but this is referred to as nuchal rigidity. It does not constitute a positive Brudzinski’s sign. Neck extension is not associated with a positive Brudzinski’s sign. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 17 Type: MCSA The nurse is assessing cranial nerve XI (spinal accessory). Which of the following statements would the nurse say to the client? 1. “Shrug your shoulders and turn your head against my hand.” 2. “Stick out your tongue and move it from side to side.” 3. “Taste these foods and decide which is sweet and which is sour.” 4. “Smell these items and identify what they are.” Correct Answer: 1 Rationale 1: The spinal accessory nerve (cranial nerve XI) controls shoulder and neck movements. The examiner planning to test this nerve should ask the client to shrug the shoulders and turn the head. Rationale 2: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue. Rationale 3: The facial nerve (cranial nerve VII) is responsible for the sense of taste. Rationale 4: Smell is controlled by the olfactory nerve (cranial nerve I). Global Rationale: The spinal accessory nerve (cranial nerve XI) controls shoulder and neck movements. The examiner planning to test this nerve should ask the client to shrug the shoulders and turn the head. The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue. The facial nerve (cranial nerve VII) is responsible for the sense of taste and symmetrical facial movements. Smell is controlled by the olfactory nerve (cranial nerve I). Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system. Question 18 Type: MCMA The nurse is performing a neurological assessment and needs to assess for vibration, as well as sharp and dull sensation. The nurse would use which of the following objects to obtain this information? Standard Text: Select all that apply. 1. Tuning fork

2. Paper clip 3. Safety pin 4. Cotton ball 5. Tongue blade Correct Answer: 1,3 Rationale 1: Tuning fork. To test for sharp and dull sensation, areas of the client’s skin are touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the client’s body. Rationale 2: Paper clip. To test for sharp and dull sensation, areas of the client’s skin are touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the client’s body. Rationale 3: Safety pin. To test for sharp and dull sensation, areas of the client’s skin are touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the client’s body. Rationale 4: Cotton ball. The trigeminal nerve (cranial nerve V) may be evaluated by using a wisp of cotton to touch the face. Rationale 5: Tongue blade. The gag reflex may be evaluated by using a tongue blade. Global Rationale: To test for sharp and dull sensation, areas of the client’s skin are touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the client’s body. The paper clip may be used to assess for the ability to determine the identity of an object unseen. A cotton ball may be used to assess sensation when evaluating the facial nerve. A tongue blade would be used to assess the gag reflex and the movements of the tongue. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system. Question 19 Type: MCSA The nurse has assessed a client and notes diminished reflexes. The nurse would correctly document which of the following? 1. 4+/0-4+ 2. 3+/0-4+

3. 2+/0-4+ 4. 1+/0-4+ Correct Answer: 1 Rationale 1: 4+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive. Rationale 2: 3+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive. Rationale 3: 2+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive. Rationale 4: 1+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive. Global Rationale: Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system. Question 20 Type: MCSA The nurse is interviewing a client and notes that the left eyelid is drooping. The nurse would correctly chart which of the following conditions? 1. Ptosis 2. Nystagmus 3. Strabismus 4. Myopia Correct Answer: 1 Rationale 1: Ptosis, or a dropped lid, is usually related to weakness of the muscles. Rationale 2: Nystagmus is an involuntary movement of the eyeball.

Rationale 3: Strabismus causes deviation of one or both eyes and is due to lack of muscular coordination. Rationale 4: Myopia is a visual disturbance in which the individual is unable to see objects that are at a distance. Global Rationale: Ptosis, or a dropped lid, is usually related to weakness of the muscles. Nystagmus is an involuntary movement of the eyeball. Strabismus causes deviation of one or both eyes and is due to lack of muscular coordination. Myopia is a visual disturbance in which the individual is unable to see objects that are at a distance. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system. Question 21 Type: MCSA The nurse observes drainage from a client’s ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. Which of the following descriptions would best support this finding? 1. Yellow without sediment 2. Blood-tinged without sediment 3. Clear, colorless 4. Pink without sediment Correct Answer: 3 Rationale 1: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Yellow drainage is not consistent with cerebral spinal fluid. Rationale 2: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Blood-tinged fluid is not consistent with cerebral spinal fluid. Rationale 3: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Rationale 4: It is important to recognize CSF as clear and colorless. Pink drainage without sediment is not consistent with cerebral spinal fluid. Global Rationale: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Yellow drainage is not consistent with normal cerebral spinal fluid. Blood-tinged fluid is not consistent with normal cerebral spinal fluid. Pink drainage without sediment is not consistent with cerebral spinal fluid.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system. Question 22 Type: MCSA The nurse notes that a client has difficulty with ambulation due to an unsteady gait. The nurse would correctly document this finding as which of the following? 1. Flaccidity 2. Paralysis 3. Hemiparesis 4. Ataxia Correct Answer: 4 Rationale 1: Flaccidity refers to muscle tone. The flaccid body part is not toned but is limp. Rationale 2: Paralysis refers to the inability to move parts of the body. Rationale 3: Hemiparesis refers to a weakness on one side of the body. Rationale 4: Ataxia refers to the loss of balance or coordination. Global Rationale: Ataxia refers to loss of balance and/or coordination. Flaccidity refers to muscle tone. Paralysis refers to the inability to move parts of the body. Hemiparesis refers to a weakness on one side of the body. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system. Question 23 Type: MCSA The nurse is interviewing a client that states he does not have any feeling on right side of the body. After confirmation of this subjective data, the nurse would correctly document which of the following?

1. Anesthesia 2. Analgesia 3. Hypalgesia 4. Hypoesthesia Correct Answer: 1 Rationale 1: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased, but not absent, sensation. Rationale 2: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased, but not absent, sensation. Rationale 3: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased, but not absent, sensation. Rationale 4: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased, but not absent, sensation. Global Rationale: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased, but not absent, sensation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system. Question 24 Type: MCSA The nurse is admitting a client with suspected meningitis. During the assessment, the nurse asks the client to flex the chin down toward the chest. The client verbalizes pain and stiffness during this action. The nurse would document this as which of the following? 1. Muscle spasms 2. Neck strain 3. Nuchal rigidity 4. Brudzinski’s sign Correct Answer: 3

Rationale 1: Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck stiffness. The presence of muscle spasms are not associated with meningitis and are not elicited in this manner. Rationale 2: Neck strain is not associated with meningitis. The assessment of neck strain would not involve having the client flex the chin toward the chest. Rationale 3: Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck stiffness. Rationale 4: Brudzinski’s sign is assessed in clients suspected of having meningitis. The sign is present when neck flexion causes flexion of the legs and thighs Global Rationale: Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck stiffness. The presence of muscle spasms are not associated with meningitis and are not elicited in this manner. Neck strain is not associated with meningitis. The assessment of neck strain would not involve having the client flex the chin toward the chest. Brudzinski’s sign is assessed in clients suspected of having meningitis. The sign is present when neck flexion causes flexion of the legs and thighs. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system. Question 25 Type: MCSA While interviewing a client the nurse notes the client’s eyes moving involuntarily. The nurse would correctly document which of the following findings? 1. Nystagmus 2. Presbyopia 3. Anosmia 4. Polyneuritis Correct Answer: 1 Rationale 1: Nystagmus is an abnormal, involuntary eye movement. Rationale 2: Presbyopia is an eye disorder in which the individual loses the ability to see objects that are near. Rationale 3: Anosmia refers to the absence of the sense of smell. Rationale 4: Polyneuritis refers to nerve inflammation.

Global Rationale: Nystagmus is an involuntary eye movement. Presbyopia is visual disturbances. Polyneuritis refers to nerve inflammation. Anosmia refers to the absence of smell. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system. Question 26 Type: MCSA The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. The nurse would correctly chart which of the following? 1. Hyperreflexia 2. Babinski response 3. Brudzinski sign 4. Nuchal rigidity Correct Answer: 2 Rationale 1: Hyperreflexia refers to a reflex that is abnormally strong. Rationale 2: The Babinski response is fanning of the toes with the great toe pointing downward when the sole of the foot is stimulated. This response is considered abnormal in adults. Rationale 3: Brudzinski sign refers to flexion of the legs and thighs when the neck is flexed and is an assessment used to confirm meningitis. Rationale 4: Nuchal rigidity refers to stiffness of the neck and is most often seen in meningitis. Global Rationale: The Babinski response is fanning of the toes with the great toe pointing downward when the sole of the foot is stimulated. This response is considered abnormal in adults. The findings described do not support hyperreflexia. Hyperreflexia refers to a reflex that is abnormally strong. Brudzinski sign refers to flexion of the legs and thighs when the neck is flexed and is an assessment used to confirm meningitis. Nuchal rigidity refers to stiffness of the neck and is most often seen in meningitis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24.5: Describe developmental, cultural, psychosocial, and environmental variations in assessment techniques and findings of the neurologic system.

Question 27 Type: MCSA 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. Older adults experience fewer accidents and injuries. 2. Alcohol or drug use increases the risk for accidents and injury. 3. Head injuries are more common in adults than children. 4. Epilepsy occurs only in children under age 15. Correct Answer: 2 Rationale 1: Older adults experience more accidents and injuries. Rationale 2: Alcohol or drug use does increase the risk for accidents and injury and neurologic disorders. Rationale 3: Head injuries are more common in children than adults. Rationale 4: Epilepsy occurs across the age span. Global Rationale: Alcohol or drug use does increase the risk for accidents and injury and neurologic disorders. Older adults experience more accidents and injury. Head injuries are more common in children than adults. Epilepsy occurs across the age span. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.5: Describe developmental, cultural, psychosocial, and environmental variations in assessment techniques and findings of the neurologic system. Question 28 Type: MCSA 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. Soft diet 2. Seizure precautions 3. Fall precautions

4. Intake and output Correct Answer: 3 Rationale 1: Syncope is a sudden, brief loss of consciousness, and the nurse would need to provide safety for a client experiencing this condition. Dietary changes may be indicated for problems with chewing or swallowing but not for syncope. Rationale 2: Syncope is a sudden, brief loss of consciousness, and the nurse would need to provide safety for a client experiencing this condition. Seizure precautions may be indicated for an individual with a seizure-related disorder but not for the presence of syncope. Rationale 3: Syncope is a sudden, brief loss of consciousness, and the nurse would need to provide safety for a client experiencing this condition. Rationale 4: Intake and output may be assessed for a variety of conditions but are not directly needed by the client experiencing episodes of syncope. Global Rationale: Syncope is a sudden, brief loss of consciousness, and the nurse would need to provide safety for a client experiencing this condition. Dietary changes may be indicated for problems with chewing or swallowing but not for syncope. Seizure precautions may be indicated for an individual with a seizure-related disorder but not for the presence of syncope. Intake and output may be indicated for a variety of medical conditions but are not indicated for the presence of syncope. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.7: Apply critical thinking in selected simulations related to physical assessment of the neurologic system. Question 29 Type: MCSA The nurse is observing a client’s ambulation abilities and notes a scissors gait. The nurse would suspect which of the following disorders in this client? 1. Parkinson’s disease 2. Multiple sclerosis 3. Myasthenia gravis 4. Muscular dystrophy Correct Answer: 2

Rationale 1: The client with Parkinson’s disease displays stooped posture a shuffling gait. This is known as a festination gait. Rationale 2: A scissors gait is characterized by spastic lower limb movement with stiffness and jerkiness. The knees come together, the legs come in front of each other, and the legs are abducted as short, slow steps are taken. This gait is associated with multiple sclerosis. Rationale 3: The client with myasthenia gravis has muscle weakness, and facial abnormalities such as ptosis are consistent with the condition. The client with muscular dystrophy has muscle weakness and may present with a waddling gait or walk on the toes to promote balance. Rationale 4: The client with muscular dystrophy has muscle weakness and may present with a waddling gait or walk on the toes to promote balance. Global Rationale: A scissors gait is characterized by spastic lower limb movement with stiffness and jerkiness. The knees come together, the legs come in front of each other, and the legs are abducted as short, slow steps are taken. This gait is associated with multiple sclerosis. The client with Parkinson’s disease displays stooped posture a shuffling gait. This is known as a festination gait. The client with myasthenia gravis has muscle weakness, and facial abnormalities such as ptosis are consistent with the condition. The client with muscular dystrophy has muscle weakness and may present with a waddling gait or walk on the toes to promote balance. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.7: Apply critical thinking in selected simulations related to physical assessment of the neurologic system. Question 30 Type: MCSA The nurse is assessing cognitive function in a client who experienced a cerebral vascular accident. The nurse should focus on which of the following? 1. Ability to smell items while eyes are closed 2. Orientation to time, place, and person 3. Ability to walk with a smooth, steady gait 4. Ability to speak clearly Correct Answer: 2 Rationale 1: Cognitive function refers to mental abilities. The assessment of mental abilities may be performed by determining the client’s orientation to time, place, and person. The ability to smell objectives while the eyes are closed is a means of assessing cranial nerve function.

Rationale 2: Cognitive function refers to mental abilities. The assessment of mental abilities may be performed by determining the client’s orientation to time, place, and person. Rationale 3: Cognitive function refers to mental abilities. The assessment of mental abilities may be performed by determining the client’s orientation to time, place, and person. The ability to walk smoothly with a steady gait and to speak clearly are items that may be included in the assessment of a client who has had a cerebral vascular accident but these reflect motor function and do not reflect cognitive abilities. Rationale 4: Cognitive function refers to mental abilities. The assessment of mental abilities may be performed by determining the client’s orientation to time, place, and person. The ability to walk smoothly with a steady gait and to speak clearly are items that may be included in the assessment of a client who has had a cerebral vascular accident but these reflect motor function and do not reflect cognitive abilities. Global Rationale: Cognitive function refers to mental abilities. The assessment of mental abilities may be performed by determining the client’s orientation to time, place, and person. The ability to smell objectives while the eyes are closed is a means of assessing cranial nerve function. The ability to walk smoothly with a steady gait and to speak clearly are items that may be included in the assessment of a client who has had a cerebral vascular accident but these reflect motor function and do not reflect cognitive abilities. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.7: Apply critical thinking in selected simulations related to physical assessment of the neurologic system. Question 31 Type: MCSA The nurse is providing discharge instructions to the mother of a child admitted for fever of unknown origin. Which of the following statements, if made by the mother, would indicate the need for further instruction? 1. “I should use Tylenol or aspirin to bring down the temperature.” 2. “I should contact the doctor if I cannot wake up my child.” 3. “I should observe how much my child urinates.” 4. “I should monitor my child’s intake of fluids throughout the day.” Correct Answer: 1 Rationale 1: Aspirin should not be administered to ill children due to the risk of Reye’s syndrome. Rationale 2: An inability to wake the child would indicate a worsening condition warranting contact with the healthcare provider.

Rationale 3: The child with an elevated temperature is at risk for dehydration. Observation of oral intake and urinary output will aid in determining fluid status. Rationale 4: The child with an elevated temperature is at risk for dehydration. Observation of oral intake and urinary output will aid in determining fluid status. Global Rationale: Aspirin should not be administered to ill children due to the risk of Reye’s syndrome. Reye’s syndrome is a condition of unknown etiology that may strike children. The disease affects the major organs of the body. The remaining statements are correct and should be included in the teaching plan for a child with a febrile illness. An inability to wake the child would indicate a worsening condition warranting contact with the healthcare provider. The child with an elevated temperature is at risk for dehydration. Observation of oral intake and urinary output will aid in determining fluid status. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 24.7: Apply critical thinking in selected simulations related to physical assessment of the neurologic system. Question 32 Type: MCMA The nurse is reviewing questions to include in a focused assessment on a client who has presented to the clinic with complaints of back pain. Which of the following questions should be included in the interview? Standard Text: Select all that apply. 1. “How long have you been experiencing this pain?” 2. “What activities seem to increase your pain?” 3. “Do any members of your family have neurological problems?” 4. “What things do you do to relieve your pain?” 5. “Are you able to perform your employment responsibilities since the pain began?” Correct Answer: 1,2,3,4,5 Rationale 1: “How long have you been experiencing this pain?” The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. When investigating pain the nurse will need to assess characteristics of the pain, including duration. Rationale 2: “What activities seem to increase your pain?” The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being

reviewed. Investigation of the pain will include information about factors associated with both activities that increase pain and those that relieve it. Rationale 3: “Do any members of your family have neurological problems?” The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. Certain neurological problems may have familial links and this potential should be investigated. Rationale 4: “What things do you do to relieve your pain?” The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. Activities that will relieve the pain should be included in the focused assessment. Rationale 5: “Are you able to perform your employment responsibilities since the pain began?” The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. The impact of the pain on the client’s abilities to manage normal activities is included in the focused assessment. Global Rationale: The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. When considering neurological concerns questions should include those about symptoms, pain, behaviors associated with the complaints, and the impact of the pain. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2: Develop questions to be used when completing the focused interview. Question 33 Type: MCSA The community health nurse is preparing a program geared toward primary prevention of hypertension. When preparing the program, what activities will aid the nurse in meeting the goals of primary prevention? 1. Providing dietary counseling for clients with hypertension 2. Offering free blood pressure screening to participants 3. Having a contest for participants to win an automatic blood pressure cuff for home use 4. Providing literature to discuss modifiable risk factors Correct Answer: 4 Rationale 1: The focus of secondary prevention is the reduction of risks and complications to the client who already has a disorder. Providing dietary counseling is an example of secondary prevention. Rationale 2: The focus of secondary prevention is the reduction of risks and complications to the client who already has a disorder. Providing blood pressure screening is an example of secondary prevention.

Rationale 3: The focus of secondary prevention is the reduction of risks and complications to the client who already has a disorder. Providing contests for a free blood pressure cuff is an example of secondary prevention. Rationale 4: Primary prevention activities seek to reduce the incidence of disease. There are risk factors associated with hypertension. Change in modifiable risk factors may result in the reduction of disease incidence. Global Rationale: Primary prevention activities seek to reduce the incidence of disease. There are risk factors associated with hypertension. Change in modifiable risk factors may result in the reduction of disease incidence. The focus of secondary prevention is the reduction of risks and complications to the client who already has a disorder. Providing dietary counseling, blood pressure screenings, and contests for a free blood pressure cuff are examples of secondary prevention. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.6: Discuss the focus areas regarding neurologic health as stated in the Healthy People 2020 initiatives. Question 34 Type: MCSA The nurse is providing education to a group of pregnant women. The nurse should stress which of the following as the greatest tool in the prevention of low-birth-weight babies? 1. Early prenatal care 2. Eating a balanced diet 3. Avoiding stress 4. Regular exercise Correct Answer: 1 Rationale 1: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status. Rationale 2: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status. A balanced diet is important during pregnancy but not all complications of pregnancy are nutrition related. Rationale 3: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status. Avoidance of stress is beneficial during pregnancy but will not prevent the majority of pregnancy related complications.

Rationale 4: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status. With monitoring and approval of the healthcare provider, regular exercise is beneficial to the pregnant woman. Exercise, however, does not prevent the greatest number of pregnancy related complications. Global Rationale: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status. A balanced diet, avoidance of stress, and exercise are beneficial but not as important as obtaining early, regular prenatal care. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.6: Discuss the focus areas regarding neurologic health as stated in the Healthy People 2020 initiatives.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 25 Question 1 Type: MCSA The nurse is performing an assessment on a 13-year–old adolescent. Which of the following findings would be unexpected? 1. Apical heart rate of 110 beats per minute 2. Respiratory rate of 14 breaths per minute 3. Blood pressure of 98/58 4. Temperature of 98.8 degrees Fahrenheit Correct Answer: 3 Rationale 1: A 13-year-old adolescent’s heart rate normally ranges from 65 to 120 beats per minute. Rationale 2: A 13-year-old adolescent’s respiratory rate normally ranges from 14 to 20 breaths per minute. Rationale 3: A 13-year-old adolescent’s blood pressure usually ranges from 110 to 131 mm Hg (systolically), and 64 to 84 mm Hg (diastolically). Rationale 4: The 13-year-old adolescent’s temperature is within normal limits. Global Rationale: A 13-year-old adolescent’s blood pressure usually ranges from 110 to 131 mm Hg (systolically), and 64 to 84 mm Hg (diastolically). This 13-year-old adolescent’s blood pressure is low. A 13-yearold adolescent’s heart rate normally ranges from 65 to 120 beats per minute. A 13-year-old adolescent’s respiratory rate normally ranges from 14 to 20 breaths per minute. The 13-year-old adolescent’s temperature is within normal limits. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.1: Identify anatomical differences between children and adults. Question 2 Type: MCSA The nurse is performing an assessment of a 7 month old. Which of the following findings may be unexpected? 1. The anterior fontanelle is closed.

2. The posterior fontanelle is closed. 3. The head is disproportionately large in comparison to the body. 4. There are two “baby teeth” present. Correct Answer: 1 Rationale 1: The anterior fontanelle usually closes when the infant is between 9 and 18 months of age. It is an unexpected finding to determine the infant’s anterior fontanelle is already closed at the age of 7 months. Rationale 2: The posterior fontanelle usually closes by the age of 2 months. Rationale 3: The head remains disproportionately large in comparison to the body until approximately 5 years of age. Rationale 4: The child should have at least one tooth present in the mouth by 15 months of age. Global Rationale: The anterior fontanelle usually closes when the infant is between 9 and 18 months of age. It is an unexpected finding to determine the infant’s anterior fontanelle is already closed at the age of 7 months. The posterior fontanelle usually closes by the age of 2 months. The head remains disproportionately large in comparison to the body until approximately 5 years of age. The child should have at least one tooth present in the mouth by 15 months of age. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.1: Identify anatomical differences between children and adults. Question 3 Type: MCSA The nurse is assessing a newborn when the mother asks about the tiny white “bumps” on the forehead and nose. The nurse would respond to the mother with which of the following statements? 1. “Those are milia and they are very common.” 2. “That is lanugo and it is very common.” 3. “Those are Mongolian spots.” 4. “Those are salmon patches.” Correct Answer: 1 Rationale 1: Milia are tiny (less than 0.5 mm), smooth, white cysts of the hair follicle found commonly on the forehead and nose at birth.

Rationale 2: Lanugo is a covering of fine hair in newborns found on the upper chest, shoulders, and back. Rationale 3: Mongolian spots are areas of dark bluish pigmentation and are most commonly found at the base of the spine. Rationale 4: Salmon patches, also known as stork bites, are small macules and patches caused by visible intradermal capillaries and are found on the forehead, eyelids, upper lip, nasal bridge, and nape of the neck. Global Rationale: Milia are very small (less than 0.5 mm), smooth, white cysts of the hair follicle found commonly on the forehead and nose at birth. Milia are normal infant variations. Lanugo is a covering of fine hair in newborns found on the upper chest, shoulders, and back. Mongolian spots are areas of dark bluish pigmentation and are most commonly found at the base of the spine. Salmon patches, also known as stork bites, are small macules and patches caused by visible intradermal capillaries and are found on the forehead, eyelids, upper lip, nasal bridge, and nape of the neck. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.1: Identify anatomical differences between children and adults. Question 4 Type: MCSA The nurse is preparing to perform an assessment on four children. After reviewing each child’s admitting diagnosis, which of the following children may have an enlarged spleen? 1. 14 year old admitted with acute gastroenteritis 2. 17 year old admitted with an acute exacerbation of asthma 3. 11 year old admitted with an umbilical hernia 4. 9 year old admitted with a sickle cell crisis Correct Answer: 4 Rationale 1: It would be unlikely that the 14 year old with acute gastroenteritis would exhibit splenomegaly (enlarged spleen). Rationale 2: It would be unlikely that the 17 year old with an acute exacerbation of asthma would exhibit splenomegaly (enlarged spleen). Rationale 3: It would be unlikely that the 11 year old with an umbilical hernia would exhibit splenomegaly (enlarged spleen). Rationale 4: Splenomegaly is common in young children with sickle cell disease (SCD). All children with SCD should be assessed for splenomegaly (enlarged spleen).

Global Rationale: Splenomegaly (enlarged spleen) is common in young children with sickle cell disease (SCD). All children with SCD should be assessed for splenomegaly. It would be unlikely that the 14 year old with acute gastroenteritis would exhibit splenomegaly. It would be unlikely that the 17 year old with an acute exacerbation of asthma would exhibit splenomegaly. It would be unlikely that the 11 year old with an umbilical hernia would exhibit splenomegaly. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.1: Identify anatomical differences between children and adults. Question 5 Type: MCSA The parents of a 3-year-old child with a history of frequent otitis media incidences ask the nurse why their child continues to have this issue. Which of the following is the nurse’s best response? 1. Children of this age frequently put things in their ears. 2. The eustachian tubes are shorter, more level, and straighter in children this age. 3. Children of this age experience more difficulty washing their hands appropriately. 4. The child has a hearing problem that is causing this to occur more frequently. Correct Answer: 2 Rationale 1: Putting objects in the ear is possible, but not necessarily typical of children of this age. Rationale 2: Children under 4 years of age are more prone to develop otitis media. The eustachian tubes of young children are shorter, straighter, and more level than in older children. Rationale 3: Children of this age probably do experience more difficulty washing their hands appropriately. However, the best response for the parents is to discuss the anatomical differences in their young child’s ears that make the child more likely to develop otitis media. Rationale 4: A hearing problem would not cause the otitis media, but frequent ear infections may result in a hearing problem. Global Rationale: Children under 4 years of age are more prone to develop otitis media. The eustachian tubes of young children are shorter, straighter, and more level than in older children. Putting objects in the ear is possible, but not necessarily typical of children of this age. Children of this age probably do experience more difficulty washing their hands appropriately. However, the best response for the parents is to discuss the anatomical differences in their young child’s ears that make the child more likely to develop otitis media. A hearing problem would not cause the otitis media, but frequent ear infections may result in a hearing problem. Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.1: Identify anatomical differences between children and adults. Question 6 Type: MCMA The mother of a 17-year-old female has brought her daughter in for an examination. Which of the following statements by the client is most consistent with the client’s most likely diagnosis?

Standard Text: Select all that apply. 1. “I usually just feel so tired.” 2. “I’ve been growing this strange, soft, light-colored ‘fur’ all over.” 3. “Everyone says I’m thin, but I don’t feel like I look thin.” 4. “I perspire all of the time and my skin is so oily.” 5. “I’m sorry, but I cannot get warm. Can you turn up the heat in this place?” Correct Answer: 1,2,3,5 Rationale 1: “I usually just feel so tired.” This young lady is most likely suffering from anorexia nervosa. It is common for clients who are suffering from anorexia nervosa to complain of feeling weak and tired. Rationale 2: “I’ve been growing this strange, soft, light-colored ‘fur’ all over.” Lanugo is a soft white hair growth on the client with anorexia nervosa. Rationale 3: “Everyone says I’m thin, but I don’t feel like I look thin.” Clients with anorexia nervosa commonly feel that they are not underweight, although they are exceedingly thin. Rationale 4: “I perspire all of the time and my skin is so oily.” Clients with anorexia nervosa more commonly complain of dry skin, not excessive perspiration and oily skin. Rationale 5: “I’m sorry, but I cannot get warm. Can you turn up the heat in this place?” The client with anorexia nervosa often suffers from cold intolerance.

Global Rationale: This young lady is most likely suffering from anorexia nervosa. It is common for clients who are suffering from anorexia nervosa to complain of feeling weak and tired. Lanugo is a soft white hair growth on the client with anorexia nervosa. Clients with anorexia nervosa commonly feel that they are not thin, although they are exceedingly thin. Clients with anorexia nervosa more commonly complain of dry skin, not excessive perspiration. The client with anorexia nervosa often suffers from cold intolerance. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 7 Type: MCMA The child has been diagnosed with acute otitis media. Which of the following findings by the nurse are consistent with this diagnosis? Standard Text: Select all that apply. 1. Temperature is 101.4 degrees Fahrenheit. 2. The tympanic membrane is pearly gray. 3. The mother states, “I cannot get her to eat anything. She just picks at her food.” 4. The mother states, “She has been so fussy.” 5. The mother states, “She can sleep only while she’s sitting up on my lap while I’m in the rocking chair.” Correct Answer: 1,3,4,5 Rationale 1: Temperature is 101.4 degrees Fahrenheit. This child has a fever, which is consistent with acute otitis media. Rationale 2: The tympanic membrane is pearly gray. The tympanic membrane of a child with acute otitis media will be orange-red or red and bulging with purulent drainage within the middle ear space. A pearly gray tympanic membrane is a normal finding. Rationale 3: The mother states, “I cannot get her to eat anything. She just picks at her food.” The child is anorexic and not eating well currently. This is consistent with acute otitis media. Rationale 4: The mother states, “She has been so fussy.” Irritability is associated with acute otitis media. Rationale 5: The mother states, “She can sleep only while she’s sitting up on my lap while I’m in the rocking chair.” Children with acute otitis media may not be able to sleep while lying down.

Global Rationale: This child has a fever, which is consistent with acute otitis media. The child is anorexic and not eating well currently. This is consistent with acute otitis media. Irritability is associated with acute otitis media. Children with acute otitis media may not be able to sleep while lying down. The tympanic membrane of a child with acute otitis media will be orange-red or red and bulging with purulent drainage within the middle ear space. A pearly gray tympanic membrane is a normal finding. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 8 Type: FIB The child has been admitted to the Intensive Care Unit following a motor vehicle accident. The child weighs 39 pounds. Calculate the child’s minimum expected urinary output in milliliters over an 8-hour period. Round to the nearest whole number. milliliters Standard Text: Correct Answer: 142 milliliters Rationale: Normal urine output for children is at least 1 ml/kg/hr. The child weighs 39 pounds. To calculate the child’s weight in kilograms, 39 pounds is divided by 2.2. There are 2.2 pounds in each kilogram. The child should produce at least 1 milliliter per kilogram each hour. The child weighs 17.727 kilograms. Multiply this number by 1 milliliter/kilogram. This is 17.727 milliliters of urine produced each hour. Multiply this number by 8, and it equals 141.818. When rounded to a whole number, this is 142 milliliters. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 9 Type: MCMA An 18-month-old child is brought to the emergency room with difficulty breathing. The physician diagnoses the child with epiglottitis. Which of the following findings by the nurse are consistent with this diagnosis? Standard Text: Select all that apply. 1. Oxygen saturation level is 85% on room air.

2. Respiratory rate is 22 per minute. 3. Stridor is audible without stethoscope. 4. Apical heart rate is 72 beats per minute. 5. Temperature is 103.7 degrees Fahrenheit. Correct Answer: 1,3,5 Rationale 1: Oxygen saturation level is 85% on room air. The child with epiglottitis may have a decreased oxygen saturation level. 85% is lower than normal. Rationale 2: Respiratory rate is 22 per minute. The respiratory rate is normal for a child between 1 and 2 years old. The child with epiglottitis will more likely exhibit an increased respiratory rate. Rationale 3: Stridor is audible without stethoscope. Audible stridor is associated with epiglottitis. Rationale 4: Apical heart rate is 72 beats per minute. The child’s heart rate is within normal limits for the child’s age. Rationale 5: Temperature is 103.7 degrees Fahrenheit. The child has a high fever and this is associated with epiglottitis. Global Rationale: The child with epiglottitis may have a decreased oxygen saturation level. 85% is lower than normal. The child with epiglottitis will more likely exhibit an increased respiratory rate. Audible stridor is associated with epiglottitis. The child has a high fever and this is associated with epiglottitis. The respiratory rate is normal for a child between 1 and 2 years old. The child’s heart rate is within normal limits for the child’s age. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child; Question 10 Type: MCSA The nurse is assessing the newborn and notes the presence of a bluish discoloration of the hands and feet. Which of the following actions would be most important for the nurse to perform next? 1. Assess the oral mucosa. 2. Obtain the newborn’s temperature. 3. Apply a blanket. 4. Assess capillary refill.

Correct Answer: 1 Rationale 1: Acrocyanosis is the bluish discoloration of the hands and feet. It is a common finding in newborns and infants during times of stress and exposure to cold environments. The nurse must differentiate this benign finding from true cyanosis by examining the oral mucosa. Rationale 2: The newborn may be suffering from hypothermia, but the nurse should first determine if the newborn is experiencing true cyanosis or acrocyanosis. Rationale 3: Applying a blanket is important, but the nurse must first determine if the newborn is experiencing true cyanosis or acrocyanosis. Rationale 4: Capillary refill is important to assess, but the most important thing to do at this point, is to determine if the newborn is experiencing true cyanosis or acrocyanosis. Global Rationale: Acrocyanosis is the bluish discoloration of the hands and feet. It is a common finding in newborns and infants during times of stress and exposure to cold environments. The nurse must differentiate this benign finding from true cyanosis by examining the oral mucosa. In true cyanosis, the oral mucosa, lips, and tongue will also be cyanotic. The newborn may be suffering from hypothermia, but the nurse should first determine if the newborn is experiencing true cyanosis or acrocyanosis. Applying a blanket is important, but the nurse must first determine if the newborn is experiencing true cyanosis or acrocyanosis. Capillary refill is important to assess, but the most important thing to do at this point is to determine if the newborn is experiencing true cyanosis or acrocyanosis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 11 Type: MCSA The nurse has assessed a 7-year-old female. The child has a moderate amount of pubic and axillary hair. The mother states, “I just think she is going through puberty early. I was 11 when I went through these changes.” The nurse’s best response would be: 1. “Your daughter is very young to be experiencing these types of changes.” 2. “You are probably right, since you went through these types of changes early.” 3. “This type of hair growth is normally associated with cardiovascular disorders.” 4. “Are her friends experiencing the same changes?” Correct Answer: 1

Rationale 1: The presence of pubic, facial, or axillary hair in a prepubescent child is indicative of endocrinologic disease. Rationale 2: The nurse should not give any diagnosis, but alert the mother that this is not a normal finding in a child of this age. Rationale 3: The presence of pubic, facial, or axillary hair in a prepubescent child is indicative of endocrinologic disease. Rationale 4: Whether or not her friends are experiencing the same changes does not address this specific child’s issues. Global Rationale: The nurse should not give any diagnosis, but alert the mother that this is not a normal finding in a child of this age. The mother was not necessarily “early” to begin changes at 11 years of age. The presence of pubic, facial, or axillary hair in a prepubescent child is indicative of endocrinologic disease. Whether or not her friends are experiencing the same changes does not address this specific child’s issues. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 12 Type: FIB The 5-year-old child’s mother asks how much her child’s bladder can hold. She states, “It seems like if we visit my mother who lives 2 hours away, we always have to stop once so that my child can pee. I just wondered how big his bladder may be.” Calculate the maximum amount of urine that the child can hold within the bladder in milliliters. milliliters Standard Text: Correct Answer: 210 milliliters Rationale: To calculate this number, use the following equation: Age in years + 2 oz = 5 + 2 oz= 7 oz. There are 30 milliliters in every ounce. 7 oz times 30 milliliters is 210 milliliters. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 13 Type: MCSA The mother of a 7-year-old child states, “I’m concerned because I can feel a few lumps at the base of his neck.” The nurse notes slightly enlarged, firm, nontender, cervical lymph nodes. The lymph nodes are easily moveable under the skin. Which of the following interventions would be appropriate? 1. Speak with the physician about acquiring a throat culture. 2. Assess the client’s temperature. 3. Examine the child’s tonsils for tonsillitis. 4. Explain to the mother that this is a normal finding. Correct Answer: 4 Rationale 1: The client is not exhibiting any clinical manifestations associated with pharyngitis, so a throat culture is not warranted. Rationale 2: The client is not exhibiting any clinical manifestations of an infection that would result in hyperthermia. Rationale 3: The client is not exhibiting any clinical manifestations of tonsillitis. Rationale 4: “Shotty” lymph nodes are a normal variant in preschool and school-age children, and are noninfected, nontender, enlarged nodes that move when palpated. Global Rationale: “Shotty” lymph nodes are a normal variant in preschool and school-age children, and are noninfected, nontender, enlarged nodes that move when palpated. The client is not exhibiting any clinical manifestations associated with pharyngitis, so a throat culture is not warranted. The client is not exhibiting any clinical manifestations of an infection that would result in hyperthermia. The client is not exhibiting any clinical manifestations of tonsillitis. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 14 Type: MCSA The nurse is interviewing the mother of a 6 month old during a well-child visit. The mother reports that there is a watery drainage from the infant’s left eye with some crusting present within the eyelashes. The nurse inspects the infant’s left eye and agrees with the mother’s assessment. In which of the following ways would the nurse accurately document this finding?

1. Exotropia 2. Esotropia 3. Dacryostenosis 4. Congenital cataracts Correct Answer: 3 Rationale 1: Exotropia causes the covered eye to move outward (laterally). Rationale 2: Esotropia causes the covered eye to move inward (medially). Rationale 3: Dacryostenosis is the congenital blockage of the tear ducts and is a normal variant until 9 months of age. The infant with dacryostenosis will present with unilateral tearing and non-purulent crusting. Rationale 4: Congenital cataracts cause the cornea to appear hazy or cloudy. Global Rationale: Dacryostenosis is the congenital blockage of the tear ducts and is a normal variant until 9 months of age. The infant with dacryostenosis will present with unilateral tearing and nonpurulent crusting. Exotropia causes the covered eye to move outward (laterally). Esotropia causes the covered eye to move inward (medially). Congenital cataracts cause the cornea to appear hazy or cloudy. Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 15 Type: MCSA The nurse is assessing a newborn and abducts the hips and palpates the greater and lesser trochanter while flexing the hips and knees at a 90-degree angle. The nurse is assessing which of the following? 1. Barlow’s maneuver 2. Knee fracture 3. Galeazzi sign 4. Ortolani’s maneuver Correct Answer: 4

Rationale 1: Barlow’s maneuver. Barlow’s maneuver is also used to assess for hip dysplasia. The nurse utilizes the same hand palpation position while the nurse adducts the hip while gently lifting the thigh and placing pressure on the trochanter. Rationale 2: Knee fracture. This assessment is not performed specifically to assess for knee fractures. Rationale 3: Galeazzi sign. Galeazzi sign is positive when the infant has differing knee heights. Rationale 4: Ortolani’s maneuver. The procedure described is called Ortolani’s maneuver and is used to assess dysplasia of the hip. Global Rationale: The procedure described is called Ortolani’s maneuver and is used to assess dysplasia of the hip. Barlow’s maneuver, which also assesses hip dysplasia, utilizes the same hand palpation position while the nurse adducts the hip while gently lifting the thigh and placing pressure on the trochanter. This assessment is not performed specifically to assess for knee fractures. Galeazzi sign is positive when the infant has differing knee heights. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 16 Type: MCMA The nurse is performing an otoscopic examination in a child and notes the child expressing pain as the pinna is manipulated to better examine the tympanic membrane. Which of the following findings is consistent with the most likely condition? Standard Text: Select all that apply. 1. Erythema is noted along the child’s ear canal. 2. The tympanic membrane is in a full position, amber-colored, and immobile. 3. The external ear is abnormally protruding forward. 4. Edema is noted within the child’s ear canal. 5. Light yellow drainage is noted within the ear canal. Correct Answer: 1,4,5 Rationale 1: Erythema is noted along the child’s ear canal. Otitis externa results a reddened ear canal. Rationale 2: The tympanic membrane is in a full position, amber-colored, and immobile.Otitis media with effusion appears with non-purulent fluid in the middle ear space, causing edema in the eustachian tubes.

Rationale 3: The external ear is abnormally protruding forward. Mastoiditis causes the child’s external ear to protrude forward. Rationale 4: Edema is noted within the child’s ear canal. Otitis externa results in edema within the ear canal. Rationale 5: Light yellow drainage is noted within the ear canal. Purulent drainage from the ear canal can indicate that the child has developed otitis externa. Global Rationale: Otitis externa results in pain with pinna manipulation and red, edematous ear canals with or without purulent discharge. Otitis media with effusion appears with nonpurulent fluid in the middle ear space, causing edema in the eustachian tubes. Mastoiditis causes the child’s external ear to protrude forward. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 17 Type: MCSA The nurse needs to assess the young child’s gait and range of motion of the extremities. Which of the following instructions is a commonly used method during this portion of the child’s assessment? 1. “I need you to pretend to be a duck. Squat and move forward while flapping your arms.” 2. “Let me see you jump in place on both feet.” 3. “Please hop across the room on one foot and then come back by hopping on the other foot.” 4. “Would you please do some jumping jacks for me?” Correct Answer: 1 Rationale 1: The duck walk involves squatting and moving forward while flapping the upper arms and can be used to evaluate normal range of motion, muscle strength, and coordination in a child. Rationale 2: Jumping in place on both feet will not provide information about range of motion of all of the child’s extremities. Rationale 3: Hopping on one foot and then the other across a room will not provide information about range of motion. Rationale 4: Jumping jacks may be difficult for some young children to perform due to lack of coordination and is not a commonly used method for assessing gait and range of motion of the extremities. Global Rationale: The duck walk involves squatting and moving forward while flapping the upper arms and can be used to evaluate normal range of motion, muscle strength, and coordination in a child. Jumping in place on

both feet will not provide information about range of motion of all of the child’s extremities. Hopping on one foot and then the other across a room will not provide information about range of motion. Jumping jacks may be difficult for some young children to perform due to lack of coordination and is not a commonly used method for assessing gait and range of motion of the extremities. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 18 Type: MCSA The nurse is examining a child. The child’s pharynx is reddened, with yellow exudate noted on each tonsil. The tongue is red with enlarged taste buds. Petechiae are visualized on the child’s soft palate near the uvula. Which of the following physician orders is most important and appropriate for this child? 1. Saline mouth rinses 2. Throat culture 3. Dental referral 4. Aspirin for pain Correct Answer: 2 Rationale 1: Saline mouth rinses may help with the client’s discomfort but is not the most important intervention. This child needs to be started on the appropriate antibiotic if the child has strep throat. Rationale 2: Strep throat infection, caused by group A beta-hemolytic Streptococcus pyogenes, may cause yellow tonsillar exudates, erythematous and edematous pharynx, red tongue with prominent taste buds (strawberry tongue), and petechial hemorrhages on the soft palate near the uvula. Rationale 3: A dental referral is inappropriate. This child needs to be started on the appropriate antibiotic if the child has strep throat. Rationale 4: Aspirin for pain is inappropriate because it can result in Reye’s syndrome when taken by children. Global Rationale: Strep throat infection, caused by group A beta-hemolytic Streptococcus pyogenes, may cause yellow tonsillar exudates, erythematous and edematous pharynx, red tongue with prominent taste buds (strawberry tongue), and petechial hemorrhages on the soft palate near the uvula. Saline mouth rinses may help with the client’s discomfort but is not the most important intervention. A dental referral is inappropriate. This child needs to be started on the appropriate antibiotic if the child has strep throat. Aspirin for pain is inappropriate because it can result in Reye’s syndrome when taken by children. Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 19 Type: MCSA The nurse is assessing a newborn and notes that the infant has six fingers on the left hand. The nurse would accurately document this information in which of the following ways? 1. Syndactyly 2. Polydactyly 3. Brachial plexus injury 4. Erb’s palsy Correct Answer: 2 Rationale 1: Syndactyly is a term used to describe the presence of webbed fingers. Rationale 2: Polydactyly is the presence of extra fingers. Rationale 3: Entire brachial plexus palsy results in no movement of the shoulder, arm, and hand. Unfortunately, this type of brachial plexus injury has a poor prognosis. Rationale 4: Erb’s palsy is one type of brachial plexus injury. It is a transient condition that results in paralysis of the shoulder and upper arm. Global Rationale: Polydactyly is the presence of extra fingers. Syndactyly is a term used to describe the presence of webbed fingers. A brachial plexus injury results in paralysis of the shoulder and upper arm from birth trauma. Entire brachial plexus palsy results in no movement of the shoulder, arm, and hand. Unfortunately, this type of brachial plexus injury has a poor prognosis. Erb’s palsy is one type of brachial plexus injury. It is a transient condition that results in paralysis of the shoulder and upper arm. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 20 Type: MCSA The nurse is assessing the child and notes that there is a depression in the lower part of the sternum. The nurse would accurately document this finding in which of the following ways?

1. Normal sternal border 2. Pectus carinatum 3. Barrel chest 4. Pectus excavatum Correct Answer: 4 Rationale 1: A normal sternum does not contain these types of depressions or bowing. Rationale 2: Pectus carinatum is also called pigeon chest. It is associated with a bowing of the sternum. Rationale 3: Barrel chest, or an increased anterioposterior chest diameter, is normally seen in infancy, or with chronic respiratory disorders and normal aging. Rationale 4: Pectus excavatum is also called funnel chest. It is associated with a depression in the lower part of the sternum. Global Rationale: Pectus excavatum is also called funnel chest. It is associated with a depression in the lower part of the sternum. A normal sternum does not contain these types of depressions or bowing. Pectus carinatum is also called pigeon chest. It is associated with a bowing of the sternum. Barrel chest, or an increased anterioposterior chest diameter, is normally seen in infancy, or with chronic respiratory disorders and normal aging. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 21 Type: FIB The nurse is educating the child’s parents about the importance of limiting the child’s intake of fruit juice to less than 12 ounces each day. Calculate the number of ounces the child has had during the last 24 hours. 120 milliliters of orange juice, 60 milliliters of grape juice, 90 milliliters of cranberry-grape juice ounces Standard Text: Correct Answer: 9 ounces Rationale: There are 30 milliliters in 1 ounce. The child drank 270 milliliters of fruit juice during the last 24 hours. 270 milliliters divided by 30 milliliters/ ounce = 9 ounces. Global Rationale:

Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child. Question 22 Type: MCSA The nurse is performing an otoscopic examination of a 3-year-old child. As the nurse prepares to examine the client’s tympanic membrane with the ototscope, the nurse would correctly choose which of the following techniques? 1. Pull the tragus up and back while inserting the otoscope. 2. Pull the ear lobe up and back while inserting the otoscope. 3. Pull the ear lobe down and back while inserting the otoscope. 4. Pull the tragus down and back while inserting the otoscope. Correct Answer: 4 Rationale 1: The tragus should be manipulated up and back when examining an older child’s tympanic membrane. Rationale 2: The tragus, not the ear lobe, should be manipulated up and back when examining an older child’s tympanic membrane. Rationale 3: The nurse should not manipulate the child’s ear lobe while inserting the otoscope. It would be more helpful to pull the child’s tragus down and back to insert the otoscope correctly. Rationale 4: In children under the age of 4 years, the tragus should be pulled down and back while the otoscope is inserted. This allows for the speculum to follow the curve of the auditory canal. Global Rationale: In children under the age of 4, the tragus should be pulled down and back while the otoscope is inserted. This allows for the speculum to follow the curve of the auditory canal. Manipulating the ear lobe will be less helpful to the nurse who wishes to examine the child’s ear. The tragus, not the ear lobe, should be manipulated up and back when examining an older child’s tympanic membrane. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.3: Use techniques that foster child compliance and safety during physical assessment. Question 23 Type: MCSA

The nurse determines that nutritional education is needed for the family of an 8 month old after the history reveals the following: the infant is drinking whole milk 3 times a day from a bottle, eats table food such as hot dogs and grapes with the 2-year-old sibling, and is allowed gum as a reward for good behavior. Which part of the data would the nurse be able to support as being correct for a child of this age? 1. Consumption of whole milk 2. Eating table foods such as hot dogs and grapes 3. Has been given gum for good behavior 4. Drinking from a bottle Correct Answer: 4 Rationale 1: An infant of this age should be consuming commercial, iron-fortified formula or breast milk. Whole milk is introduced, usually in a cup, at 1 year of age. Rationale 2: The child should not be consuming hot dogs or grapes, as both are choking hazards. These types of foods could produce choking in the 2-year-old sibling as well, and would not be recommended. Rationale 3: Rewarding an 8-month-old infant for good behavior with a choking hazard such as gum is inappropriate. Rationale 4: The best information reported about this child’s nutritional consumption is that the infant continues to drink from a bottle. It is unlikely that a child of this age would be able to drink effectively from a cup. Global Rationale: The best information reported about this child’s nutritional consumption is that the infant continues to drink from a bottle. It is unlikely that a child of this age would be able to drink effectively from a cup. An infant of this age should be consuming commercial, iron-fortified formula or breast milk. Whole milk is introduced, usually in a cup, at 1 year of age. The child should not be consuming hot dogs or grapes, as both are choking hazards, even for the 2-year-old sibling. Rewarding an 8-month-old infant for good behavior with a choking hazard such as gum is inappropriate. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.4: Incorporate the physical, cognitive, and emotional development of children into comprehensive health assessment. Question 24 Type: MCMA The student nurse is preparing to perform an assessment on a 5-year-old Arab American child with a possible case of otitis media. The experienced nurse accompanies the student nurse. Which of the following statements by the student nurse indicate that further education is required?

Standard Text: Select all that apply. 1. “It would be best to have the child sit in his mom’s lap if we have to give him a shot.” 2. “Before I listen to the child’s lungs, I can let him play with my stethoscope.” 3. “I will be able to see the tympanic membrane more clearly if I pull the tragus down and back.” 4. “It really doesn’t matter what his culture is; mommies always make the decisions about children’s health care issues.” 5. “I’m going to have to be firm but friendly with my approach to the child.” Correct Answer: 1,3,4 Rationale 1: “It would be best to have the child sit in his mom’s lap if we have to give him a shot.” Painful procedures should not be performed while a child is seated on a parent’s lap. Children need to know they are safe from painful experiences when they are with their parents. Rationale 2: “Before I listen to the child’s lungs, I can let him play with my stethoscope.” Whenever possible, play should be incorporated into nursing procedures. It is helpful to allow children to touch and manipulate equipment. Rationale 3: “I will be able to see the tympanic membrane more clearly if I pull the tragus down and back.” The student nurse should pull the pinna up and back because the child is older than 4 years of age. Rationale 4: “It really doesn’t matter what his culture is; mommies always make the decisions about children’s health care issues.” Arab Americans have patriarchal hierarchies where the father must be consulted prior to any professional healthcare decisions. Rationale 5: “I’m going to have to be firm but friendly with my approach to the child.” Nurses should use a caring, supportive, yet firm approach with children. Global Rationale: Painful procedures should not be performed while a child is seated on a parent’s lap. Children need to know they are safe from painful experiences when they are with their parents. The student nurse should pull the pinna up and back because the child is older than 4 years of age. Arab Americans have patriarchal hierarchies where the father must be consulted prior to any professional healthcare decisions. Whenever possible, play should be incorporated into nursing procedures. It is helpful to allow children to touch and manipulate equipment. Nurses should use a caring, supportive, yet firm approach with children. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.4: Incorporate the physical, cognitive, and emotional development of children into comprehensive health assessment. Question 25 Type: MCMA

The nurse is performing an assessment on the following 5 newborns. Which of the newborns does the nurse expect to exhibit Mongolian spots? Standard Text: Select all that apply. 1. African American newborn 2. Caucasian newborn 3. Hispanic newborn 4. Native American newborn 5. Asian newborn Correct Answer: 1,3,4,5 Rationale 1: African American newborn. African American newborns commonly exhibit Mongolian spots. Rationale 2: Caucasian newborn. The Caucasian newborn does not commonly exhibit Mongolian spots. Rationale 3: Hispanic newborn. The Hispanic newborn commonly exhibits Mongolian spots. Rationale 4: Native American newborn. The Native American newborn commonly exhibits Mongolian spots. Rationale 5: Asian newborn. The Asian newborn commonly exhibits Mongolian spots. Global Rationale: African American newborns commonly exhibit Mongolian spots. The Hispanic newborn commonly exhibits Mongolian spots. The Native American newborn commonly exhibits Mongolian spots. The Asian newborn commonly exhibits Mongolian spots. The Caucasian newborn does not commonly exhibit Mongolian spots. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.4: Incorporate the physical, cognitive, and emotional development of children into comprehensive health assessment. Question 26 Type: MCSA The student nurse is preparing to provide care for several newborns and their families. The experienced nurse is present to ensure appropriate care is provided. Which of the following statements by the student nurse indicates that further education is required? 1. “The newborn’s parents recently moved here from Mexico, so we need to ensure that the baby is tested for sickle cell anemia.”

2. “When dealing with the Chinese parents, it is important to remember that they may not make a lot of direct eye contact when I’m talking with them.” 3. “When dealing with the parents from Mexico, I must make sure that I do not touch the baby when I compliment him.” 4. “The baby’s parents were raised on the Indian reservation. We should make sure the baby is tested for hypothyroidism.” Correct Answer: 3 Rationale 1: Babies from Hispanic parents should be tested for sickle cell anemia. Rationale 2: Chinese parents are more likely to avoid direct eye contact. Rationale 3: When dealing with Hispanic families, it is important to touch the baby while complimenting the baby. Many Mexican Americans believe that it is bad luck to compliment a child without touching the child. It results in the “evil eye.” Rationale 4: Native American babies are prone to developing hypothyroidism. Global Rationale: When dealing with Hispanic families, it is important to touch the baby while complimenting the baby. Many Mexican Americans believe that it is bad luck to compliment a child without touching the child. It results in the “evil eye.” Babies from Hispanic parents should be tested for sickle cell anemia. Chinese parents are more likely to avoid direct eye contact. Native American babies are prone to developing hypothyroidism. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.4: Incorporate the physical, cognitive, and emotional development of children into comprehensive health assessment. Question 27 Type: MCMA The nurse has reviewed the objectives of Healthy People 2020 related to children’s health issues. As the nurse looks through a magazine, several articles seem to be related specifically to the objectives. Which of the following articles are associated with these objectives? Standard Text: Select all that apply. 1. The three best ways to keep your children safe from guns in your home. 2. Back to sleep, baby; the importance of placing your baby on his or her back to sleep. 3. A strong marriage means strong children.

4. My daughter wouldn’t stop drinking while she was pregnant; how I helped her. 5. I am a teen and I took the pledge not to text and drive. Correct Answer: 1,2,4,5 Rationale 1: The three best ways to keep your children safe from guns in your home. Firearm safety is listed as one of the objectives of Healthy People 2020 to reduce rate of child deaths. Rationale 2: Back to sleep, baby; the importance of placing your baby on his or her back to sleep. Education for caregivers about ways to reduce an infant’s risk of developing SIDS is an objective of Healthy People 2020. Rationale 3: A strong marriage means strong children. The importance of strong marriages is not listed as an objective of Healthy People 2020. Rationale 4: My daughter wouldn’t stop drinking while she was pregnant; how I helped her. The use of alcohol while a woman is pregnant may increase the fetus’ or infant’s risk of death and is listed as an objective of Healthy People 2020. Rationale 5: I am a teen and I took the pledge not to text and drive. The importance of safe handling of automobiles is listed as an objective of Healthy People 2020. Global Rationale: Firearm safety is listed as one of the objectives to reduce rate of child deaths. Education for caregivers about ways to reduce an infant’s risk of developing SIDS is an objective of Healthy People 2020. The use of alcohol while a woman is pregnant may increase the fetus’ or infant’s risk of death. The importance of safe handling of automobiles is listed as an objective. The importance of strong marriages is not listed as an objective of Healthy People 2020. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 25.5: Discuss the objectives in Healthy People 2020 as they relate to infant and child health. Question 28 Type: MCSA The nurse presented an educational program for parents regarding children and adolescent health issues noted specifically in Healthy People 2020. Following the program, the nurse listened to several people talking to each other about the contents of the program. Which of the following statements made by program participants indicate that further education is required? 1. “No one needs training to put in a car seat. Parents just need to buy them.” 2. “As parents, we have to actively watch our children to make sure they remain safe.” 3. “After that program, I realize that my 14 year old may need psychologic counseling for depression. I just thought he was in a blue funk, but he could actually try to commit suicide.”

4. “Up until now, I’ve let older children swim alone without supervision. That is going to stop.” Correct Answer: 1 Rationale 1: Parents should be educated about the appropriate ways to place and use car seats to reduce child deaths. Car seat placement is very important and critical to prevent injury during accidents. Rationale 2: Parents should be educated regarding the use of active supervision as a mechanism to decrease child injury risk. Rationale 3: Parents should recognize teens that are in need of psychologic counseling to help prevent suicide. Rationale 4: Parents should use active supervision while young people are swimming to reduce their risk of injury or death. Global Rationale: Parents should be educated about the appropriate ways to place and use car seats to reduce child deaths. Car seat placement is very important and critical to prevent injury during accidents. Parents should be educated regarding the use of active supervision as a mechanism to decrease child injury risk. Parents should recognize teens that are in need of psychologic counseling to help prevent suicide. Parents should use active supervision while young people are swimming to reduce their risk of injury or death. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 25.5: Discuss the objectives in Healthy People 2020 as they relate to infant and child health. Question 29 Type: MCMA The 15 month old has been diagnosed with acute otitis media. Which of the following nursing diagnoses would be most applicable? Standard Text: Select all that apply. 1. Acute pain 2. Hyperthermia 3. Nutrition: altered, more than body requirements 4. Risk for caregiver role strain 5. Decreased cardiac output Correct Answer: 1,2,4 Rationale 1: Acute pain. Children with acute middle ear infections typically suffer from acute ear pain.

Rationale 2: Hyperthermia. They are more likely to develop a fever. Hyperthermia is an appropriate nursing diagnosis. Rationale 3: Nutrition: altered, more than body requirements. The child with acute otitis media is usually anorexic and less likely to be receiving adequate amounts of nourishment. Rationale 4: Risk for caregiver role strain. The child’s caregivers must be assessed to determine if they are stressed. Many parents of ill children are sleep deprived because of their child’s altered sleep patterns. Rationale 5: Decreased cardiac output. If there are any alterations with the child’s cardiac output, the child with a fever may have an increased cardiac output, rather than a decreased cardiac output. Global Rationale: Children with acute middle ear infections typically suffer from acute ear pain. They are more likely to develop a fever. The child’s caregivers must be assessed to determine if they are stressed. Many parents of ill children are sleep deprived because of their child’s altered sleep patterns. The child is usually anorexic and less likely to be receiving adequate amounts of nourishment. If there are any alterations with the child’s cardiac output, the child with a fever may have an increased cardiac output, rather than a decreased cardiac output. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.6: Apply critical thinking in selected simulations of pediatric physical assessment. Question 30 Type: FIB The child is prescribed an antibiotic for an acute middle ear infection. The child weighs 38 pounds. The antibiotic is available as 200 milligrams in 5 milliliters. The physician writes an order for the child to receive 45 milligrams per 1 kilogram of body weight each day, divided in three equal doses. Calculate the amount of medicine the child should receive per dose. Round to the tenths place. milliliters Standard Text: Correct Answer: 6.5 milliliters Rationale: The child weighs 38 pounds, or 17.273 kilograms. For each kilogram of body weight the child is supposed to receive 45 milligrams of medicine each day. 17.273 x 45= 777.273 milligrams of antibiotic per day. When this number is divided by 3 (doses), it is 259.091 milligrams per dose. The medicine is available as 200 milligrams in 5 milliliters. Use dimensional analysis, ratio-proportion, or formula such as: (Ordered/Available) x Quantity. The child should receive 6.477 milliliters, or when rounded to the tenths place, 6.5 milliliters of antibiotic. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.6: Apply critical thinking in selected simulations of pediatric physical assessment.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 26 Question 1 Type: MCMA A pregnant client reports concern about the development of reddish marks on her abdomen and breasts. The client asks about having a cream prescribed to help them disappear. What information should be included in the teaching provided to the client regarding this inquiry? Standard Text: Select all that apply. 1. The stretch marks will fade but not disappear. 2. Cream will help the skin stay supple. 3. Cocoa butter lotions and creams will clear the marks completely. 4. The marks will lighten to a silvery tone after pregnancy. 5. Wearing supportive undergarments will help to support the skin and reduce the appearance of the marks. Correct Answer: 1,2,4 Rationale 1: The stretch marks will fade but not disappear. Striae gravidarum are known as stretch marks. They commonly occur during pregnancy. They result from the stretching of the skin to accommodate fetal growth. These marks will not disappear but will fade and lighten after the pregnancy ends. Rationale 2: Cream will help the skin stay supple. There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple. Rationale 3: Cocoa butter lotions and creams will clear the marks completely. These marks will not disappear but will fade and lighten after the pregnancy ends. There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple. Rationale 4: The marks will lighten to a silvery tone after pregnancy. These marks will not disappear but will fade and lighten after the pregnancy ends. Rationale 5: Wearing supportive undergarments will help to support the skin and reduce the appearance of the marks. Wearing supportive undergarments will help promote comfort to the growing abdomen but will not prevent the development of stretch marks. Global Rationale: Striae gravidarum are known as stretch marks. They commonly occur during pregnancy. They result from the stretching of the skin to accommodate fetal growth. These marks will not disappear but will fade and lighten after the pregnancy ends. There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple. Wearing supportive undergarments will help promote comfort to the growing abdomen but will not prevent the development of stretch marks.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female. Question 2 Type: MCSA A client who is 38 weeks pregnant reports she has been experiencing urinary frequency. Which response by the nurse is indicated? 1. “Your reports are consistent with a urinary tract infection.” 2. “I will need to check your blood sugar as excessive urination is associated with gestational diabetes.” 3. “Reducing your fluid intake will be helpful to manage this problem.” 4. “This is normal occurrence in the later stages of pregnancy.” Correct Answer: 4 Rationale 1: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications the client has a urinary tract infection. Rationale 2: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications the client has an elevation in blood glucose levels. Rationale 3: The health of the pregnancy requires adequate fluid intake. Reduction of fluid intake is problematic as it will reduce fluids available to the fetus. In addition, the condition is not being caused by an increased oral fluid intake. Rationale 4: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. Global Rationale: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications the client has an elevation in blood glucose levels or a urinary tract infection. The health of the pregnancy requires adequate fluid intake. Reduction of fluid intake is problematic as it will reduce fluids available to the fetus. In addition, the condition is not being caused by an increased oral fluid intake. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female. Question 3 Type: MCSA The nurse is reading the history and physical on a pregnant client and reads that the cervix was noted as soft in texture and nontender during the pelvic examination. The nurse would correctly identify this as which of the following? 1. Piscacek’s sign 2. Goodell’s sign 3. Chadwick’s sign 4. Hegar’s sign Correct Answer: 2 Rationale 1: Piscacek’s sign is when the shape of the uterus becomes irregular due to the implantation of the ovum. Rationale 2: During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodell’s sign. Rationale 3: Chadwick’s sign is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Rationale 4: Hegar’s sign occurs throughout pregnancy and is the softening of the region that connects the body of the uterus and the cervix. Global Rationale: During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodell’s sign. Chadwick’s sign, also occurring during pregnancy, is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Piscacek’s sign is when the shape of the uterus becomes irregular due to the implantation of the ovum. Hegar’s sign occurs throughout pregnancy and is the softening of the region that connects the body of the uterus and the cervix. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female. Question 4 Type: MCSA

The nurse is assessing the fundal height of a pregnant client and notes the fundus is halfway between the symphysis pubis and the umbilicus. The nurse would correctly estimate the weeks in pregnancy as which of the following? 1. 10–12 2. 16 3. 20–22 4. 38 Correct Answer: 2 Rationale 1: At 10 to 12 weeks the fundus is slightly above the symphysis pubis. Rationale 2: At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. Rationale 3: Between 20 and 22 weeks the fundus reaches the umbilicus. Rationale 4: At 38 weeks the fundus is above the umbilicus. Global Rationale: At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. At 10 to 12 weeks the fundus is slightly above the symphysis pubis, and between 20 and 22 weeks the fundus reaches the umbilicus and increases above this until 38 weeks. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female. Question 5 Type: HOTSPOT The nurse is assessing the abdomen of a client who is 20 weeks gestation. Indicate the anticipated height of the fundus.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The fundal height can be anticipated passed upon gestational age. At 20 weeks gestation, the fundal height will be at the level of the umbilicus. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female. Question 6 Type: MCSA The nurse is interviewing a female client who reports no menstrual periods for 2 months and breast soreness. The nurse would document this data as which classification of signs of pregnancy? 1. Objective 2. Probable 3. Presumptive 4. Positive Correct Answer: 3 Rationale 1: Objective findings are those things that are measurable as opposed to subjective findings that are condition reports by an individual that cannot directly be validated. Rationale 2: Probable signs are those that may be documented by an examiner and include positive pregnancy test, abdominal enlargement, Piskacek’s sign, Hegar’s sign, Goodell’s sign, Chadwick’s sign, and Braxton Hicks contractions.

Rationale 3: Presumptive signs of pregnancy are symptoms the client reports that may have multiple causes other than pregnancy. These include amenorrhea, breast tenderness, nausea and vomiting, frequent urination, perceived quickening, skin changes, and fatigue. Rationale 4: Positive signs of pregnancy have no possible explanation other than pregnancy and include hearing the fetal heart tone and visualization of the fetus with ultrasound or radiology. Global Rationale: Presumptive signs of pregnancy are symptoms the client reports that may have multiple causes other than pregnancy. These include amenorrhea, breast tenderness, nausea and vomiting, frequent urination, perceived quickening, skin changes, and fatigue. Probable signs are those that may be documented by an examiner and include positive pregnancy test, abdominal enlargement, Piskacek’s sign, Hegar’s sign, Goodell’s sign, Chadwick’s sign, and Braxton Hicks contractions. Positive signs of pregnancy have no possible explanation other than pregnancy and include hearing the fetal heart tone and visualization of the fetus with ultrasound or radiology. Objective findings are those things that are measurable as opposed to subjective findings that are condition reports by an individual that cannot directly be validated. Many of the presumptive and all of the probable and positive signs of pregnancy are objectives findings. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female. Question 7 Type: MCSA The healthcare provider is performing an assessment on a pregnant client. The examiner notes a softening in the area being assessed. Review the photograph below and identify the probable sign of pregnancy being assessed.

1. Goodell’s sign 2. Hegar’s sign 3. Chadwick’s sign 4. Ladin’s sign Correct Answer: 1 Rationale 1: Goodell’s sign refers to the softening of the cervix. Rationale 2: Hegar’s sign refers to the softening of the lower uterine segment. Rationale 3: Chadwick’s sign refers to the change in coloration of the mucous membranes of the female genitalia during pregnancy Rationale 4: Ladin’s sign refers to the softening of the mid uterus during pregnancy. Global Rationale: Goodell’s sign refers to the softening of the cervix. Hegar’s sign refers to the softening of the lower uterine segment. Chadwick’s sign refers to the change in coloration of the mucous membranes of the female genitalia during pregnancy. Ladin’s sign refers to the softening of the mid uterus during pregnancy. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that guide assessment in pregnancy and postpartum. Question 8 Type: MCSA The nurse is performing a pelvic examination on a client who is 20 weeks pregnant and notes a white, odorless discharge from the vagina. The nurse would correctly choose which of the following actions? 1. Ask the client about vaginal discomfort. 2. Inquire about recent sexual intercourse. 3. Obtain a culture of the discharge. 4. Document the findings as normal. Correct Answer: 4 Rationale 1: During pregnancy it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment. Rationale 2: During pregnancy it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment. Rationale 3: During pregnancy it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment. Rationale 4: During pregnancy it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment. Global Rationale: During pregnancy it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leucorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that guide assessment in pregnancy and postpartum. Question 9 Type: MCSA

The nurse is assessing a postpartum client and notes the peri-pad has whitish-yellow discharge. The nurse would correctly document this vaginal discharge as which of the following? 1. Postpartal bleeding 2. Lochia rubra 3. Lochia serosa 4. Lochia alba Correct Answer: 4 Rationale 1: To refer to the discharge simply as postpartal bleeding does not provide an adequate description. Rationale 2: The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called lochia. The initial lochia rubra contains blood from the placental site, amniotic membrane, cells from the decidua basalis, vernix and lanugo from the infant’s skin, and meconium. It is dark red and has a fleshy odor, and lasts anywhere from 2 days to 18 days. Rationale 3: The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called lochia. Once the lochia rubra has subsided the discharge becomes pinkish and is called lochia serosa. It is composed of blood, placental site exudates, erythrocytes, leukocytes, cervical mucus, microorganisms, and decidua, and lasts approximately a week. Rationale 4: The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called lochia. In the final stages the discharge becomes whitish-yellow, lochia alba, and is composed of leukocytes, mucus, bacteria, epithelial cells, and decidua. Global Rationale: The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called lochia. The initial lochia rubra contains blood from the placental site, amniotic membrane, cells from the decidua basalis, vernix and lanugo from the infant’s skin, and meconium. It is dark red and has a fleshy odor, and lasts anywhere from 2 days to 18 days. Next the discharge becomes pinkish and is called lochia serosa. It is composed of blood, placental site exudates, erythrocytes, leukocytes, cervical mucus, microorganisms, and decidua, and lasts approximately a week. Finally, the discharge becomes whitishyellow, lochia alba, and is composed of leukocytes, mucus, bacteria, epithelial cells, and decidua. Most females will have vaginal discharge from 10 days to 5 or 6 weeks. To refer to the discharge simply as postpartal bleeding does not provide an adequate description. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that guide assessment in pregnancy and postpartum. Question 10 Type: MCSA

The nurse is assessing a client in the third trimester of pregnancy and notes a yellowish discharge from both breasts. The nurse would correctly choose which of the following actions? 1. Ask the client if she is preparing for breastfeeding. 2. Notify the healthcare provider. 3. Document the findings as normal. 4. Obtain a culture of the discharge immediately. Correct Answer: 3 Rationale 1: Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. Rationale 2: Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider. Rationale 3: Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider. Rationale 4: Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider. Global Rationale: Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that guide assessment in pregnancy and postpartum. Question 11 Type: MCSA

The nurse is assisting the healthcare provider during a vaginal examination. The healthcare provider notes the cervix has a bluish-purple change in coloration. The nurse would recognize this condition is known as: 1. Goodell’s sign 2. Leukorrhea 3. Chadwick’s sign 4. Mucous plug Correct Answer: 3 Rationale 1: Hormonal changes in pregnancy cause a series of changes to the female genitalia. The vascularity of the cervix increases contributing to the softening of the cervix, and is called Goodell’s sign. Rationale 2: Hormonal changes in pregnancy cause a series of changes to the female genitalia. Leukorrhea is a profuse, nonodorous, nonpainful, vaginal discharge, which is a normal finding. Rationale 3: Hormonal changes in pregnancy cause a series of changes to the female genitalia. Chadwick’s sign appears during pregnancy and is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Rationale 4: The endocervical canal is closed by a plug of mucus. This mucus remains in place until the final days of the pregnancy. At that time it is expelled, producing a discharge referred to as bloody show. Global Rationale: Hormonal changes in pregnancy cause a series of changes to the female genitalia. Chadwick’s sign appears during pregnancy and is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. This vascularity of the cervix also contributes to the softening of the cervix, and is called Goodell’s sign. The endocervical canal is closed by a plug of mucus. This mucus remains in place until the final days of the pregnancy. At that time it is expelled, producing a discharge referred to as bloody show. Leukorrhea is a profuse, nonodorous, nonpainful, vaginal discharge. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that guide assessment in pregnancy and postpartum. Question 12 Type: MCSA The nurse is discussing dietary recommendations with a client who has been experiencing a larger than recommended weight gain during her pregnancy. The client reports reducing the amount of empty calories and of red meat consumed while significantly increasing intake of fish, poultry, and fresh fruits and vegetables. What response is indicated by the nurse?

1. “It looks like you have things under control. Do you have any other questions? 2. “Have you considered seeing a dietitian for nutritional counseling?” 3. “Tell me more about the meat and fish you are eating each day.” 4. “I think we should discuss the risky dietary choices you are making with the healthcare provider.” Correct Answer: 3 Rationale 1: Questions should be sought from the client; however, there are areas for potential problems such as the reduction in protein sources and intake of still-undetermined varieties of fish. Rationale 2: Nutritional counseling is within the scope of practice for the nurse and a dietary consult is still premature. Rationale 3: Some of the client’s actions are positive changes. The reduction of empty calories is a good change. Red meat is a good source of protein and should not be entirely eliminated. Mercury levels can be problematic in some types of fish. The nurse will need to evaluate the types of fish being eaten. Swordfish, shark, king mackerel, and tilefish should be avoided. Intake of white tuna and game fish should also be restricted. Rationale 4: The client is making some positive changes and notification of the healthcare provider is premature. Global Rationale: Some of the client’s actions are positive changes. The reduction of empty calories is a good change. Red meat is a good source of protein and should not be entirely eliminated. Mercury levels can be problematic in some types of fish. The nurse will need to evaluate the types of fish being eaten. Swordfish, shark, king mackerel, and tilefish should be avoided. Intake of white tuna and game fish should also be restricted. It is premature to consult with the dietitian. Dietary education is within the scope of nursing practice and the client’s behaviors do not warrant further action at this time. It is premature to notify the healthcare provider of the nutritional status without additional information. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.3: Identify questions used when completing the focused interview. Question 13 Type: MCSA A client at 33 weeks gestation calls the healthcare provider’s office and reports she was attempting to nap when she became dizzy and felt faint. What assessment data should be collected by the nurse first? 1. The position the client was in during the nap period 2. Dietary intake prior to the episode 3. History of hyperemesis

4. No additional data as this appears to be an isolated incident Correct Answer: 1 Rationale 1: The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position. Rationale 2: The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position. Dietary factors and the presence of hyperemesis are not implicated in this client’s scenario. Rationale 3: The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position. Dietary factors and the presence of hyperemesis are not implicated in this client’s scenario. Rationale 4: The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position. The nurse must investigate the complaints to ensure client safety. Global Rationale: The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position. Dietary factors and the presence of hyperemesis are not implicated in this client’s scenario. The nurse must investigate the complaints to ensure client safety. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.3: Identify questions used when completing the focused interview. Question 14 Type: MCSA The healthcare provider is using Leopold’s maneuvers to assess fetal positioning. Which of the following maneuvers is being used in the figure below?

1. First Leopold’s maneuver 2. Second Leopold’s maneuver 3. Third Leopold’s maneuver 4. Fourth Leopold’s maneuver Correct Answer: 3 Rationale 1: Leopold’s maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The first maneuver places the ulnar surface of both hands on the fundus, with the fingertips pointing toward the midline to palpate the shape and firmness of the contents of the upper uterus. Rationale 2: Leopold’s maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The second maneuver moves the hands along the sides of the abdomen to palpate the contour of the uterus. Rationale 3: Leopold’s maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The third maneuver determines which part of the fetus is presenting at the pelvis. It is done by sliding the hands down to the area above the symphysis pubis to determine the “presenting” part of the fetus, the part of the fetus entering the pelvic inlet. The shape and firmness of the presenting part is palpated by using the thumb and third finger of one hand to grasp the presenting part. Rationale 4: Leopold’s maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The fourth Leopold’s maneuver is used to determine the depth of the presenting part in the pelvis. It is done by placing the

ulnar surface of your two hands on each side of the client’s abdomen and following the uterine/fetal contour to the pelvic brim. Global Rationale: Leopold’s maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The first maneuver places the ulnar surface of both hands on the fundus, with the fingertips pointing toward the midline to palpate the shape and firmness of the contents of the upper uterus. The second maneuver moves the hands along the sides of the abdomen to palpate the contour of the uterus. The third maneuver determines which part of the fetus is presenting at the pelvis. It is done by sliding the hands down to the area above the symphysis pubis to determine the “presenting” part of the fetus, the part of the fetus entering the pelvic inlet. The shape and firmness of the presenting part is palpated by using the thumb and third finger of one hand to grasp the presenting part. The fourth Leopold’s maneuver is used to determine the depth of the presenting part in the pelvis. It is done by placing the ulnar surface of your two hands on each side of the client’s abdomen and following the uterine/fetal contour to the pelvic brim. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.4: Describe techniques used in the assessment of the pregnant and postpartum female. Question 15 Type: HOTSPOT The nurse is preparing to assess the fetal heart tones for a client whose fetus is in the LOA position. Review the photograph below and draw an “X” to indicate the best location to assess for the heart tones.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The position of the fetus can be used to ascertain the best location for listening for fetal heart tones. When the fetus is in the LOA (left occiput posterior) position, the head of the fetus is the presenting part. The occipital region of the fetal head and back will be facing the left anterior side of the mother. This will allow the assessment of heart tones in a region closest to the back of the fetus. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.4: Describe techniques used in the assessment of the pregnant and postpartum female. Question 16 Type: MCSA The nurse is monitoring a pregnant client in labor and is wants to determine the length of time from the beginning of the contraction until the end of the contraction. The nurse is assessing which of the following in this client? 1. Contraction intensity 2. Contraction palpation 3. Contraction frequency 4. Contraction duration Correct Answer: 4 Rationale 1: The intensity of the contraction refers to its strength. Rationale 2: Assessing the intensity or strength of contractions is done by palpation and is described by comparing the rigidity of the uterus to the firmness of certain other body features such as the nose, the chin, and the forehead for mild, moderate, and hard. Rationale 3: The frequency of the contractions is determined by measuring the interval from the beginning of one contraction to the beginning of the next contraction.

Rationale 4: The duration of contractions is measured from the beginning of the contraction until the end of the contraction. Global Rationale: The duration of contractions is measured from the beginning of the contraction until the end of the contraction. The frequency of the contractions is determined by measuring the interval from the beginning of one contraction to the beginning of the next contraction. The intensity of the contraction refers to its strength. Assessing the intensity or strength of contractions is done by palpation and is described by comparing the rigidity of the uterus to the firmness of certain other body features such as the nose, the chin, and the forehead for mild, moderate, and hard. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.4: Describe techniques used in the assessment of the pregnant and postpartum female. Question 17 Type: MCSA The nurse is caring for a pregnant client who desires to know the estimated date of birth (EDB) for the baby. The client reports the last menstrual period (LMP) was April 10. Using Naegele’s Rule, the nurse would correctly calculate the EDB as which of the following? 1. February 1 2. May 17 3. May 24 4. January 17 Correct Answer: 4 Rationale 1: Using Naegele’s Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month. Rationale 2: Using Naegele’s Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month. Rationale 3: Using Naegele’s Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month. Rationale 4: Using Naegele’s Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month. Global Rationale: Using Naegele’s Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26.4: Describe techniques used in the assessment of the pregnant and postpartum female. Question 18 Type: MCSA The nurse is interviewing a primigravida client who is 17 weeks pregnant. During the data collection the client reports she has not felt the baby move yet. The most appropriate response by the nurse would be: 1. “We will listen for the heartbeat today.” 2. “You need an ultrasound.” 3. “Fetal movement does not occur until the 18th week.” 4. “Do you have reason to believe your baby is not ok?” Correct Answer: 3 Rationale 1: While all prenatal care appointments at this gestational age and beyond will include an assessment of the fetal heartbeat, this option does not meet the client’s need for education. Rationale 2: Ultrasounds may be performed to assess for fetal viability but there is no indication at this time the pregnancy is at risk. Rationale 3: Quickening, the fluttery initial sensations of fetal movement perceived by the mother, usually occurs at approximately 18 weeks, possibly earlier in women who have given birth before. This mother is in need of factual information from the nurse. Rationale 4: Asking if the client is feeling uneasy about the health of the pregnancy does not meet the client’s need for information. Global Rationale: Quickening, the fluttery initial sensations of fetal movement perceived by the mother, usually occurs at approximately 18 weeks, possibly earlier in women who have given birth before. This mother is in need of factual information from the nurse. While all prenatal care appointments at this gestation and beyond will include an assessment of the fetal heartbeat, this option does not meet the client’s need for education. Ultrasounds may be performed to assess for fetal viability but there is no indication at this time the pregnancy is at risk. Asking if the client is feeling uneasy about the health of the pregnancy does not meet the client’s need for information. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.5: Differentiate normal from abnormal findings in the interview and physical assessment.

Question 19 Type: MCSA The nurse is examining a client who is 37 weeks pregnant. Which of the following findings would require immediate intervention by the nurse? 1. Patellar reflex 4+/0-4+ bilaterally 2. Heart rate 104 3. Trace protein in the urine 4. Weight gain of 2 pounds in 2 months Correct Answer: 1 Rationale 1: Hyperreflexia may be indicative of preeclampsia, and there is a need for the nurse to further evaluate this finding. Evaluation of reflexes should be done using the following scale: 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive. Rationale 2: Heart rates in pregnant women are normally elevated as a result of the increased circulating volume and increases in metabolic rate. Rationale 3: Normal urine components do not include protein; however, the increased workload for the kidneys and the increased GFR may result in episodes of protein in the urine. The presence of protein in the urine warrants investigation but it is not an immediate need or of the same level of importance of the reflex findings. Rationale 4: Weight gain of 2 pounds in an 8-week period is not excessive and does not require immediate action. Global Rationale: Hyperreflexia may be indicative of preeclampsia, and there is a need for the nurse to further evaluate this finding. Evaluation of reflexes should be done using the following scale: 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive. Heart rates in pregnant women are normally elevated as a result of the increased circulating volume and increases in metabolic rate. Normal urine components do not include protein; however, the increased workload for the kidneys and the increased GFR may result in episodes of protein in the urine. The presence of protein in the urine warrants investigation but it is not an immediate need or of the same level of importance of the reflex findings. Weight gain of 2 pounds in an 8-week period is not excessive and does not require immediate action. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26.5: Differentiate normal from abnormal findings in the interview and physical assessment. Question 20 Type: MCSA

The nurse is interviewing a client who is 36 weeks pregnant. Which of the following statements, if made by the client, would require immediate intervention by the nurse? 1. “I have to get up during the night to void.” 2. “I have not felt the baby move today.” 3. “I am leaking a yellowish fluid from my breasts.” 4. “I have been taking Tylenol (acetaminophen) for my backaches.” Correct Answer: 2 Rationale 1: Urinary frequency is common during the last months of pregnancy as the uterus places pressure on the bladder. Rationale 2: The absence or change in fetal movement can signal a problem with the pregnancy. When no fetal movement has been noted in the past 8 hours, there are fewer than 10 movements in 12 hours, there is a change in the usual pattern of movements, or a sudden increase in violent fetal movements followed by a complete cessation of movement, further investigation is warranted. Immediate evaluation of the fetus should take place. Rationale 3: Pregnant women begin to produce and secrete colostrum from the breast during pregnancy. Rationale 4: Tylenol (acetaminophen) is appropriate for the back pain that accompanies third trimester pregnancy. Global Rationale: The absence or change in fetal movement can signal a problem with the pregnancy. When no fetal movement has been noted in the past 8 hours, there are fewer than 10 movements in 12 hours, there is a change in the usual pattern of movements, or a sudden increase in violent fetal movements followed by a complete cessation of movement, further investigation is warranted. Immediate evaluation of the fetus should take place. Urinary frequency is common during the last months of pregnancy as the uterus places pressure on the bladder. Pregnant women begin to produce and secrete colostrum from the breasts during pregnancy. Tylenol is appropriate for the back pain that accompanies third trimester pregnancy. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26.5: Differentiate normal from abnormal findings in the interview and physical assessment. Question 21 Type: MCMA The nurse is preparing a teaching plan for a group of pregnant clients. Which of the following should the nurse include in this teaching session? Standard Text: Select all that apply.

1. Do not use soap on my nipples. 2. Sleep 8–10 hours each night. 3. Eat four servings of dairy products daily. 4. Do not take iron supplements due to constipation. 5. Avoid resting in a back lying position. Correct Answer: 1,2,3,5 Rationale 1: Do not use soap on my nipples. The use of soap on the nipples will result in drying and should be avoided. Rationale 2: Sleep 8–10 hours each night. Pregnant women are in need of adequate rest and sleep. Sleeping 8 to 10 hours each night is recommended. Rationale 3: Eat four servings of dairy products daily. The dietary needs of the pregnant woman will involve approximately 1000 mg of calcium daily. The needed calcium can be obtained by ingesting 4 servings from the dairy group each day. Rationale 4: Do not take iron supplements due to constipation. Dietary intake during pregnancy cannot meet the iron required for the needs of both mother and baby. Iron supplements are needed to meet the needs of pregnant women. While constipation may be associated with iron supplementation, discontinuing the medication is contraindicated. The client experiencing constipation should be instructed to increase fluid and fiber intake to promote bowel regulation instead of not taking the needed iron supplements. Rationale 5: Avoid resting in a back-lying position. Lying on the back is contraindicated as the pregnancy progresses. Back-lying positions will result in the compression of the vena cava and may cause reduced perfusion, lightheadedness, and dizziness. Global Rationale: The use of soap on the nipples will result in drying and should be avoided. Pregnant women are in need of adequate rest and sleep. Sleeping 8 to 10 hours each night is recommended. The dietary needs of the pregnant woman will involve approximately 1000 mg of calcium daily. The needed calcium can be obtained by ingesting 4 servings from the dairy group each day. Dietary intake during pregnancy cannot meet the iron required for the needs of both mother and baby. Iron supplements are needed to meet the needs of the pregnant women. While constipation may be associated with iron supplementation, discontinuing the medication is contraindicated. The client experiencing constipation should be instructed to increase fluid and fiber intake to promote bowel regulation instead of not taking the needed iron supplements. Lying on the back is contraindicated as the pregnancy progresses. Back-lying positions will result in the compression of the vena cava and may cause reduced perfusion, lightheadedness, and dizziness. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 26.6: Describe the health promotion and education topics necessary in the care of the pregnant female.

Question 22 Type: MCSA A client at 33 weeks gestation has a complete blood cell count drawn. When the client hears that her hemoglobin level was higher before her pregnancy, she asks if this will increase the risk to her unborn baby. What information should be provided to the client? 1. If the client increases the number of prenatal vitamins taken, the risk to the fetus will be eliminated. 2. The fetus is at an increased risk of prematurity. 3. Dietary management will eliminate the risk to the fetus. 4. The fetus will likely suffer from anemia as well. Correct Answer: 2 Rationale 1: Changes in prenatal vitamin intake and dietary modification may improve the condition and reduce risk, but this will not totally eliminate the associated risk factors. Rationale 2: The risk to the fetus as a result of the maternal anemia includes prematurity, low birth weight, and perinatal mortality. Rationale 3: Changes in prenatal vitamin intake and dietary modification may improve the condition and reduce risk, but this will not totally eliminate the associated risk factors. Rationale 4: There is no evidence the fetus will experience anemia as a result of the maternal anemia. Global Rationale: The risk to the fetus as a result of the maternal anemia includes prematurity, low birth weight and perinatal mortality. Changes in prenatal vitamin intake and dietary modification may improve the condition and reduce risk, but this will not totally eliminate the associated risk factors. There is no evidence the fetus will experience anemia. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.6: Describe the health promotion and education topics necessary in the care of the pregnant female. Question 23 Type: MCMA The nurse is planning a prenatal education class for a group of women who are in their second trimester of pregnancy. Regarding the gestation of the pregnancy, which of the following topics are considered most appropriate?

Standard Text: Select all that apply. 1. Preparation of breasts for breastfeeding 2. Fetal development 3. Warning signs to report 4. Psychologic concerns associated with becoming pregnant 5. Preterm labor signs Correct Answer: 2,3,5 Rationale 1: Preparation of breasts for breastfeeding. Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. The preparation of breasts for breastfeeding is a topic that is best presented during the third trimester. Rationale 2: Fetal development. Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. Each educational opportunity should include information concerning fetal development and warning signs to report. Rationale 3: Warning signs to report. Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. Each educational opportunity should include information concerning fetal development and warning signs to report. Rationale 4: Psychologic concerns associated with becoming pregnant. Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. The client is most interested in discussing the psychologic concerns associated with pregnancy during the first trimester. Rationale 5: Preterm labor signs. Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. The second trimester is a period in which preterm labor becomes an increasing risk factor and should be discussed with the client. Global Rationale: Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. Each educational opportunity should include information concerning fetal development and warning signs to report. The second trimester is a period in which preterm labor becomes an increasing risk factor and should be discussed with the client. The preparation of breasts for breastfeeding is a topic that is best presented during the third trimester. The client is most interested in discussing the psychologic concerns associated with pregnancy during the first trimester. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26.6: Describe the health promotion and education topics necessary in the care of the pregnant female.

Question 24 Type: MCSA During a prenatal counseling session a client indicates concern about her potential HIV positive status. The client states she does not want to “jinx” the pregnancy by getting tested because if she is positive, so is the baby. Which statement by the nurse is indicated? 1. “You are right to avoid the stress of finding out you are HIV positive during the pregnancy.” 2. “If you are HIV positive, your baby will also have HIV.” 3. “Even if you do test HIV positive, preventive treatments have a good chance of providing protection for your baby.” 4. “As long as you do not breastfeed and have a cesarean section, your baby will be protected.” Correct Answer: 3 Rationale 1: While testing during pregnancy may be stressful to the mother, the potential benefits are immeasurable. The highest priority for the nurse is to provide education concerning the benefits of prenatal testing. Rationale 2: Prophylactic antiviral therapies can significantly reduce the incidence of transmission between mother and baby during the pregnancy. Without treatment, the risk of transmission to the baby is greatest. Rationale 3: Prophylactic antiviral therapies can significantly reduce the incidence of transmission between mother and baby during the pregnancy. Without treatment, the risk of transmission to the baby is greatest. Rationale 4: Although breastfeeding and a cesarean section delivery will reduce the rate of transmission, they are not 100% effective tools of prevention. Global Rationale: Prophylactic antiviral therapies can significantly reduce the incidence of transmission between mother and baby during the pregnancy. Without treatment, the risk of transmission to the baby is greatest. Although breastfeeding and a cesarean section delivery will reduce the rate of transmission, they are not 100% effective tools of prevention. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.7: Identify the objectives in Healthy People 2020 that apply to the pregnant female. Question 25 Type: MCMA A client at 15 weeks gestation has just been advised she has tested positive for syphilis. The client is tearful and inquires about the risk to her infant. Which of the elements will be included in the management of the condition?

Standard Text: Select all that apply. 1. The client will be treated with IV antibiotic therapy during the prenatal period. 2. The sexual partners of the client will require notification and testing. 3. The client will begin antibiotic therapy at this time. 4. The client will begin antibiotic therapy after birth of the baby. 5. The infant will require intrauterine management for the condition. Correct Answer: 2,3 Rationale 1: The client will be treated with IV antibiotic therapy during the prenatal period. The client will be managed with oral antibiotic therapy at the time of diagnosis. Rationale 2: The sexual partners of the client will require notification and testing. Syphilis is a communicable disease. It is the legal responsibility of the healthcare facility to perform the appropriate reporting. The sexual partners of the client must be notified, tested, and treated if indicated. Rationale 3: The client will begin antibiotic therapy at this time. The client will begin treatment at the time of diagnosis. Allowing the client to wait until after the birth of the baby would prolong exposure to the pathogen. Rationale 4: The client will begin antibiotic therapy after birth of the baby. The client will begin treatment at the time of diagnosis. Allowing the client to wait until after the birth of the baby would prolong exposure to the pathogen. Rationale 5: The infant will require intrauterine management for the condition. Infants born with syphilis will be treated. Therapies are not indicated for the fetus. Global Rationale: The client will begin treatment at the time of diagnosis. Allowing the client to wait until after the birth of the baby would prolong exposure to the pathogen. The condition will be managed with oral antibiotic therapy. Syphilis is a communicable disease. It is the legal responsibility of the healthcare facility to perform the appropriate reporting. The sexual partners of the client must be notified, tested, and treated if indicated. IV antibiotic therapy is not indicated. Infants who are infected with syphilis will be treated after birth. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26.7: Identify the objectives in Healthy People 2020 that apply to the pregnant female. Question 26 Type: MCSA The nurse is examining a client in the third trimester of pregnancy. Which of the following findings would require immediate intervention by the nurse?

1. Pulse of 98 beats per minute 2. Weight gain of 1.5 pounds in a month 3. Blood pressure of 148/94 4. Respiratory rate of 26 per minute Correct Answer: 3 Rationale 1: The pregnant client’s heart and respiratory rates will increase slightly due to an increased circulatory volume and a decrease in intrathoracic space. Rationale 2: Weight gain should be a pound per month in the second and third trimesters. Rationale 3: A pregnant client’s blood pressure should not be greater than 140/90 and if elevated could be a sign of gestational hypertension or preeclampsia. Rationale 4: The pregnant client’s heart and respiratory rates will increase slightly due to an increased circulatory volume and a decrease in intrathoracic space. Global Rationale: A pregnant client’s blood pressure should not be greater than 140/90 and if elevated could be a sign of gestational hypertension or preeclampsia. The pregnant client’s heart and respiratory rates will increase slightly due to an increased circulatory volume and a decrease in intrathoracic space. Weight gain should be a pound per month in the second and third trimesters. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26.8: Apply critical thinking in a selected simulation related to physical assessment of the postpartum client. Question 27 Type: MCSA The client who is at 5 weeks gestation is seen in the Emergency Department with complaints of severe abdominal and pelvic pain. A vaginal examination reveals tenderness and a palpable mass near the uterus. Based upon your knowledge, which of the following can the nurse anticipate will take place first? 1. The client will be sent home on bed rest. 2. The client will be admitted to the acute care facility for observation. 3. The client will be evaluated in the labor and delivery department with a nonstress test. 4. An ultrasound will be ordered.

Correct Answer: 4 Rationale 1: The client is presenting with manifestations consistent with an ectopic pregnancy. Sending the client home and placing her on bed rest without completing a thorough evaluation may result in harm to the client. Rationale 2: The client is presenting with manifestations consistent with an ectopic pregnancy. The findings from the ultrasound will determine the next steps in the client’s care. Rationale 3: The client is presenting with manifestations consistent with an ectopic pregnancy. The client’s gestational age is not yet advanced enough to utilize a nonstress test for evaluation. Rationale 4: The client is presenting with manifestations consistent with an ectopic pregnancy. The ultrasound will be used to assist in confirming the condition. Global Rationale: The client is presenting with manifestations consistent with an ectopic pregnancy. The ultrasound will be used to assist in confirming the condition. Sending the client home without a thorough evaluation could result in rupture of the ectopic and place the client at great risk. Observation may be indicated if the ectopic pregnancy is ruled out. The client’s gestational age is not yet advanced enough to utilize a nonstress test for evaluation. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26.8: Apply critical thinking in a selected simulation related to physical assessment of the postpartum client. Question 28 Type: MCSA A client has been diagnosed with Group B Streptococcus at 33 weeks gestation. The client becomes tearful when the diagnosis is discussed. She asks what will be done next. What information should be provided to the client? 1. The client will receive oral antibiotics to be taken over the next 7 weeks. 2. The infection will be managed with IV antibiotics when the client is in active labor. 3. Due to the limited risk of transmission, the client will begin treatment during the postpartum period. 4. The client will require IM antibiotic treatment to facilitate a rapid cure. Correct Answer: 2 Rationale 1: Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier.

Rationale 2: Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier. Rationale 3: Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier. Rationale 4: Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier. Oral and intramuscular antibiotics are not indicated for this infection. Global Rationale: Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier. Oral and intramuscular antibiotics are not indicated for this infection. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.8: Apply critical thinking in a selected simulation related to physical assessment of the postpartum client. Question 29 Type: MCSA While performing data collection for a client who has recently had her pregnancy confirmed, the client reports taking daily herbal supplements. What action by the nurse is of the highest priority? 1. Instruct the client to increase the supplements to promote nutritional well-being. 2. Advise the client to reduce the amount of supplements taken to allow for the prescribed prenatal vitamins being taken. 3. Encourage the client to speak with the healthcare provider about the herbal supplements. 4. Record the client’s reports on the permanent medical record. Correct Answer: 3 Rationale 1: Herbal supplements are not regulated. They should be avoided during the pregnancy. If taken, it should only be under the recommendation of the healthcare provider. Increasing the supplementations may endanger the fetus. Rationale 2: Herbal supplements are not regulated. They should be avoided during the pregnancy. If taken, it should only be under the recommendation of the healthcare provider. Increasing the supplementations may endanger the fetus.

Rationale 3: Herbal supplements are not regulated. They should be avoided during the pregnancy. If taken, it should only be under the recommendation of the healthcare provider. Increasing the supplementations may endanger the fetus. Rationale 4: Reports of the supplements being taken should be documented on the medical record but this is not the action of the greatest importance. The notification of the potential dangers of supplements is a higher importance. Global Rationale: Herbal supplements are not regulated. They should be avoided during the pregnancy. If taken, it should only be under the recommendation of the healthcare provider. Increasing the supplementations may endanger the fetus. Although the client’s reports are to be noted in the medical record, it is not the initial action by the nurse. The nurse’s documentation must also include the client’s response and type of supplements being ingested. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.8: Apply critical thinking in a selected simulation related to physical assessment of the postpartum client. Question 30 Type: MCMA The nurse is reviewing the tests planned for a pregnant client. Traditionally testing done for gestational diabetes will be performed between 24 and 28 weeks gestation. Which of the following findings in the client’s history will prompt the test to be performed earlier in the pregnancy? Standard Text: Select all that apply. 1. The client is a multigravida. 2. The client has a history of a previous stillbirth. 3. The client has a strong family history of diabetes. 4. The client experienced infertility prior to becoming pregnant. 5. The client’s last baby was large for gestational age. Correct Answer: 2,3,5 Rationale 1: The client is a multigravida. The number of past pregnancies does not impact the risk factors of gestational diabetes. Rationale 2: The client has a history of a previous stillbirth. Diabetic women have a higher incidence of stillbirth.

Rationale 3: The client has a strong family history of diabetes. Diabetes may have familial tendencies. Rationale 4: The client experienced infertility prior to becoming pregnant. Infertility is not directly linked to the presence of diabetes. Rationale 5: The client’s last baby was large for gestational age. Babies born to gestational diabetics are often large for gestational age as a result of uncontrolled serum glucose levels of the mother. Global Rationale: The assessment for gestational diabetes is most often done between 24 and 28 weeks gestation. In cases in which the client is deemed to be at an increased risk the testing can be done sooner. Diabetic women have a higher incidence of stillbirth. Diabetes may have familial tendencies. Babies born to gestational diabetics are often large for gestational age as a result of uncontrolled serum glucose levels of the mother. The number of past pregnancies does not impact the risk factors of gestational diabetes. Infertility is not directly linked to the presence of diabetes. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.8: Apply critical thinking in a selected simulation related to physical assessment of the postpartum client.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 27 Question 1 Type: MCSA The nurse has provided an educational program for his peers regarding several theories of aging. Which of the following statements by a participant in the program indicates the need for further education? 1. “Senescence refers to changes that organisms experience as they age.” 2. “Error theories point to stressors as the cause for aging.” 3. “Error theories indicate that aging follows a timetable.” 4. “There are several major theories of aging: programmed, error, and those theories that overlap.” Correct Answer: 3 Rationale 1: The term senescence has become the preferred terminology to distinguish changes, such as graying hair, wrinkling of the skin and others, that have no impact on viability from those changes that create risks for disease, disability, and death. Rationale 2: Error theories explain aging as the result of cellular damage in response to internal and external stressors. Rationale 3: Programmed theories, not error theories, indicate that aging follows a timetable. Rationale 4: The major categories of aging theories include programmed theories, error theories, and those that overlap. Global Rationale: Programmed theories, not error theories, indicate that aging follows a timetable. The term senescence has become the preferred terminology to distinguish changes, such as graying hair, wrinkling of the skin and others, that have no impact on viability from those changes that create risks for disease, disability, and death. Error theories explain aging as the result of cellular damage in response to internal and external stressors. The major categories of aging theories include programmed theories, error theories, and those that overlap. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 27.1: Describe several theories of aging. Question 2 Type: MCMA

The nurse is interviewing an older adult client prior to performing a head-to-toe assessment. Which of the following statements by the client indicate that the client’s skin may appear more damaged than another person this client’s age? Standard Text: Select all that apply. 1. “I know I drink too much alcohol, but why stop now?” 2. “I’ve smoked 1–2 packs per day for the last 48 years.” 3. “My sister was a ‘sun-worshipper,’ but I avoided the sun because it made my skin feel too dry.” 4. “I used to work as a radiology tech.” 5. “I was exposed to Agent Orange during the war.” Correct Answer: 1,2,4,5 Rationale 1: “I know I drink too much alcohol, but why stop now?” Older clients who have exposed their bodies to the effects of alcohol will speed up the aging that occurs within their skin. Rationale 2: “I’ve smoked 1–2 packs per day for the last 48 years.” Clients who use nicotine will exhibit more effects of skin aging than their peers who do not smoke nicotine. Rationale 3: “My sister was a ‘sun-worshipper,’ but I avoided the sun because it made my skin feel too dry.” The client’s sister may appear older due to the effects of the sun on her skin. The client avoided the sun and may not exhibit the skin effects of aging as much as her sister. Rationale 4: “I used to work as a radiology tech.” Working around radiation can increase the skin’s aging. Rationale 5: “I was exposed to Agent Orange during the war.” Older clients who have been exposed to chemicals used in warfare may look older than their stated age. Global Rationale: Older clients who have exposed their bodies to the effects of alcohol will speed up the aging that occurs within their skin. Clients who use nicotine will exhibit more effects of skin aging than their peers who do not smoke nicotine. Working around radiation can increase the skin’s aging. The client’s sister may appear older due to the effects of the sun on her skin. Older clients who have been exposed to chemicals used in warfare may look older than their stated age. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults. Question 3 Type: MCMA

The nurse is assessing the older adult client. As the nurse completes the nursing care plan for the client, which of the following places the client at risk for infection? Standard Text: Select all that apply. 1. The client has been voluntarily restricting fluid intake due to issues with incontinence. 2. The client’s skin has become thinner and drier, and the client exhibits signs of pruritis. 3. The client has decreased sebum production. 4. The gastric emptying time is delayed. 5. The client has diminished calcium absorption. Correct Answer: 1,2,3,4 Rationale 1: The client has been voluntarily restricting fluid intake due to issues with incontinence. The client who voluntarily restricts fluid intake may develop a urinary tract infection due to this practice. Rationale 2: The client’s skin has become thinner and drier, and the client exhibits signs of pruritis. The older client’s skin is thinner, drier and the client’s skin may feel itchy. When clients scratch their skin, they may break the skin and produce a portal of entry for pathogens. Rationale 3: The client has decreased sebum production. Sebum is protective. It is produced by the sebaceous gland to oil the skin and protect the skin from pathogens. Rationale 4: The gastric emptying time is delayed. Gastric emptying times are significantly slowed with aging, contributing to gastritis and peptic ulcers due to Helicobacter pylori infections. Rationale 5: The client has diminished calcium absorption. The client’s reduced calcium absorption contributes to osteoporosis, not necessarily an increased risk for infection. The client with osteoporosis has an increased risk of injuring the body after falling. Global Rationale: The client who voluntarily restricts fluid intake may develop a urinary tract infection due to this practice. The older client’s skin is thinner and drier, and the client’s skin may feel itchy. Scratching increases the risk for skin breakdown providing a portal of entry for pathogens. Sebum is protective. It is produced by the sebaceous gland to oil the skin and protect the skin from pathogens. Gastric emptying times are significantly slowed with aging, causing feelings of premature fullness and contributing to gastritis and peptic ulcers due to Helicobacter pylori infections. The client’s reduced calcium absorption contributes to osteoporosis, not necessarily an increased risk for infection. The client with osteoporosis has an increased risk of injuring the body after falling. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults.

Question 4 Type: MCSA The nurse is interviewing an elderly client and notes the presence of several soft, yellow plaques on the eyelids at the inner canthus. The nurse would suspect that the client has developed which of the following conditions? 1. Xanthelasma 2. Pingueculae 3. Pterygium 4. Arcus senilis Correct Answer: 1 Rationale 1: Xanthelasma are soft, yellow plaques on the lids at the inner canthus and are a part of normal aging, not related to vision or eye problems. Rationale 2: Pingueculae are yellowish nodules that are thickened areas of the bulbar conjunctiva caused by prolonged exposure to sun, wind, and dust. They may be on either side of the pupil. Rationale 3: Pterygium is opacity of the bulbar conjunctiva that can grow over the cornea and block vision. Rationale 4: Arcus senilis is a light gray or white ring surrounding the iris at the corneal margin due to the deposition of lipids. This is a common finding. Global Rationale: Xanthelasma are soft, yellow plaques on the lids at the inner canthus and are a part of normal aging, not related to vision or eye problems. Pingueculae are yellowish nodules that are thickened areas of the bulbar conjunctiva caused by prolonged exposure to sun, wind, and dust. They may be on either side of the pupil. Pterygium is opacity of the bulbar conjunctiva that can grow over the cornea and block vision. Arcus senilis is a light gray or white ring surrounding the iris at the corneal margin due to the deposition of lipids. This is a common finding. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.2: Identify normal anatomical and Physiologic changes in older adults. Question 5 Type: FIB The nurse is assessing the older adult client’s waist-to-hip ratio to determine the client’s risk for developing hypertension. The client’s hip circumference is 72 centimeters. The client’s waist circumference is 81 centimeters. Calculate the client’s waist-to-hip ratio. Round to the hundredths place. Standard Text:

Correct Answer: 1.13 Rationale: The client’s waist-to- hip ratio is 1.125 and when rounded to the hundredths place, it is 1.13. This client’s waist-to-hip ratio is greater than 0.95. This client has an increased risk for developing hypertension. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults. Question 6 Type: MCMA The nurse is assessing the older adult client for the presence of metabolic syndrome. Which of the following findings are consistent with the presence of this condition? Standard Text: Select all that apply. 1. The client’s waist-to-hip ratio is 0.88. 2. The client’s apical heart rate is 58 beats per minute. 3. The client’s blood pressure is 152/92. 4. The client’s serum glucose level is 312 mg/dL. 5. The client’s white blood cell count is 3,000 mm3. Correct Answer: 3,4 Rationale 1: The client’s waist-to-hip ratio is 0.88. The client’s waist-to-hip ratio is below 0.95 and this finding is not consistent with metabolic syndrome. Rationale 2: The client’s apical heart rate is 58 beats per minute. The client’s apical heart rate is decreased, which is not typically associated with metabolic syndrome. Rationale 3: The client’s blood pressure is 152/92. The client’s blood pressure is elevated, which is a finding that is consistent with metabolic syndrome. Rationale 4: The client’s serum glucose level is 312 mg/dL. The client’s serum glucose level is elevated, which is consistent with metabolic syndrome. Rationale 5: The client’s white blood cell count is 3,000 mm3. The client’s white blood cell count is decreased. The client is experiencing leukopenia. White blood cell count is not necessarily elevated or decreased in the client with metabolic syndrome.

Global Rationale: The client’s blood pressure is elevated, which is a finding that is consistent with metabolic syndrome. Metabolic syndrome is characterized by excess abdominal fat, hypertension, dyslipidemia, and insulinresistant glucose metabolism, which reportedly exists in 50 percent of adults over 60 years of age. The client’s serum glucose level is elevated, which is consistent with metabolic syndrome. The client’s waist-to-hip ratio is below 0.95 and this finding is not consistent with metabolic syndrome. The client’s apical heart rate is decreased, which is not typically associated with metabolic syndrome. The client’s white blood cell count is decreased. The client is experiencing leukopenia. White blood cell count is not necessarily elevated or decreased in the client with metabolic syndrome. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults. Question 7 Type: MCMA The nurse is assessing an older adult client who has come to the outpatient clinic with complaints of fatigue. The nurse believes that the client is exhibiting clinical manifestations associated with hypothyroidism. Which of the following findings are consistent with the presence of this condition? Standard Text: Select all that apply. 1. The client’s son states, “Sometimes, she seems a little slow to respond during our conversations, like she’s taking longer to process the information.” 2. The client’s bowel sounds are hyperactive in all four quadrants. 3. The client states, “I just don’t have the energy that I once did. Most of the time I just feel like sitting down.” 4. The client’s apical heart rate is 106 beats per minute. 5. The client’s respiratory rate is 10 breaths per minute. Correct Answer: 1,3,5 Rationale 1: The client’s son states, “Sometimes, she seems a little slow to respond during our conversations, like she’s taking longer to process the information.” Slowed mental processing can be associated with hypothyroidism. Rationale 2: The client’s bowel sounds are hyperactive in all four quadrants. Hyperactive bowel sounds are normally auscultated in clients with hyperthyroidism. Rationale 3: The client states, “I just don’t have the energy that I once did. Most of the time I just feel like sitting down.” The client’s perception that her energy level has decreased is consistent with hypothyroidism.

Rationale 4: The client’s apical heart rate is 106 beats per minute. The client’s apical heart rate is elevated, which is normally associated with hyperthyroidism. Rationale 5: The client’s respiratory rate is 10 breaths per minute. The client’s respiratory rate is decreased and this can be associated with hypothyroidism. Global Rationale: Slowed mental processing can be associated with hypothyroidism. Hypothyroidism is a condition that develops when the client is unable to produce enough thyroid hormone. The client’s perception that her energy level has decreased is consistent with hypothyroidism. The client’s respiratory rate is decreased and this can be associated with hypothyroidism. Hyperactive bowel sounds are normally auscultated in clients with hyperthyroidism. The client’s apical heart rate is elevated, which is normally associated with hyperthyroidism. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults. Question 8 Type: MCMA The nurse has assessed the older adult client and has developed a nursing care plan based on the nurse’s findings. Which of the following age-related changes validates the nurse’s inclusion of the nursing diagnosis Risk for Injury? Standard Text: Select all that apply. 1. The mucous membranes that line the respiratory passages become drier. 2. The client has developed bilateral cataracts. 3. The client has only three teeth in his mouth. 4. The client’s body mass index (BMI) is 22. 5. The client has been diagnosed with hypothyroidism. Correct Answer: 2,4,5 Rationale 1: The mucous membranes that line the respiratory passages become drier. The client with drier respiratory passages may have an increased risk of developing an infection. Rationale 2: The client has developed bilateral cataracts. The client with bilateral cataracts will not be able to see as well. This client may have an increased risk of injury due to being unable to visualize obstacles or hazards. Rationale 3: The client has only three teeth in his mouth. The client who has three teeth may not be able to receive adequate nourishment due to the inability to grind up the food with the teeth. Food must be chewed adequately for the body to be able to break down and gather nutrients from the food.

Rationale 4: The client’s body mass index (BMI) is 22. The client who has a body mass index of 22 is underweight. This client has an increased risk of developing osteoporosis. This client may injure himself more during a fall than a client who has an ideal body weight. Rationale 5: The client has been diagnosed with hypothyroidism. The client with hypothyroidism is more prone to injury because of delayed mental processing. Global Rationale: The client with bilateral cataracts will not be able to see as well. This client may have an increased risk of injury due to being unable to visualize obstacles or hazards. The client who has a body mass index of 22 is underweight. This client has an increased risk of developing osteoporosis. This client may injure himself more during a fall than a client who has an ideal body weight. The client with hypothyroidism is more prone to injury because of delayed mental processing. The client with drier respiratory passages may have an increased risk of developing an infection. The client who has three teeth may not be able to receive adequate nourishment due to the inability to grind up the food with the teeth. Food must be chewed adequately for the body to be able to break down and gather nutrients from the food. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults. Question 9 Type: MCSA The nurse is performing an assessment on a 70-year-old client. Which of the following findings will warrant further investigation? 1. Slight bulging along the lower eyelids 2. Reduced perspiration 3. Reduced sebum production 4. Large white spots on the upper arms and trunk Correct Answer: 4 Rationale 1: The loss of skin elasticity around the eyes is associated with bulging in the lower eyelids. Rationale 2: A reduction in the number of sweat glands is a normal occurrence in aging and results in a reduced production of perspiration. Rationale 3: Reduced sebum production from the sebaceous glands is a normal finding in the aging client. Rationale 4: The presence of large white spots may be vitiligo. The presence and underlying cause of integumentary changes will need to be evaluated.

Global Rationale: The presence of large white spots may be vitiligo. The presence and underlying cause of integumentary changes will need to be evaluated. The loss of skin elasticity around the eyes is associated with bulging in the lower eyelids. A reduction in the number of sweat glands is a normal occurrence in aging and results in a reduced production of perspiration. Reduced sebum production from the sebaceous glands is a normal finding in the aging client. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults. Question 10 Type: MCSA The client reports to the Emergency Department with complaints of severe pain. The client was diagnosed with a fractured hip. The client reported sitting down on the toilet seat and feeling his right hip break. The client asks how this could have happened. What information can be provided by the nurse? 1. “The body’s bones become increasingly brittle and lose density with aging.” 2. “Unfortunately, this may signal a serious underlying health problem.” 3. “You should discuss this with your healthcare provider.” 4. “There is no good explanation for what has happened to you.” Correct Answer: 1 Rationale 1: The body’s bones have an increasing loss of density with aging. It is related in part to hormone levels. Fractures can result with little stress. Rationale 2: The client’s fracture may simply be a normal adverse effect associated with aging and not associated with any serious underlying disorder. Rationale 3: Although the client should be encouraged to speak with healthcare provider, the nurse should attempt to meet the client’s needs for immediate education. Rationale 4: The nurse can explain to the client that as people age, their bones lose density and become more brittle. Global Rationale: The body’s bones have an increasing loss of density with aging. It is related in part to hormone levels. Fractures can result with little stress. The client’s fracture may simply be a normal adverse effect associated with aging and not associated with any serious underlying disorder. Although the client should be encouraged to speak with the healthcare provider, the nurse should attempt to meet the client’s needs for immediate education. The nurse can explain to the client that as people age, their bones lose density and become more brittle.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults. Question 11 Type: MCSA During a routine physical examination, a 66-year-old client reports feeling very tired throughout the day. Which of the following is the nurse’s best initial action? 1. Assess the client’s sleep patterns. 2. Encourage the client to begin to take a nap each day. 3. Encourage the client to alter the evening routine to reduce potential evening stressors. 4. Ask the healthcare provider to prescribe a medication designed to help the client sleep better. Correct Answer: 1 Rationale 1: The client’s sleep habits will need to be investigated. If they are inadequate, action will be warranted. Rationale 2: Not all clients are candidates for napping. The nurse’s first action is to assess the client’s sleep habits. Rationale 3: Although changes in the evening routine may be helpful, there is inadequate information to make that recommendation. The nurse’s first action is to assess the client’s sleep habits. Rationale 4: It is inappropriate for the nurse to make recommendations to the healthcare provider concerning a prescription at this time. The nurse’s first action is to assess the client’s sleep habits. Global Rationale: The client’s sleep habits will need to be investigated. If they are inadequate, action will be warranted. Not all clients are candidates for napping. Although changes in the evening routine may be helpful, there is inadequate information to make that recommendation. It is inappropriate for the nurse to make recommendations to the healthcare provider concerning a prescription. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults. Question 12 Type: MCMA

The nurse is preparing to interview the older adult client and perform a head-to-toe assessment. Which of the following actions by the nurse indicate the nurse requires further education? Standard Text: Select all that apply. 1. The nurse has requested that the client put on a cotton gown prior to the interview. 2. The nurse seats the client so that the light from the window faces the client with the nurse’s back to the window. 3. The nurse addresses the client by her first name. 4. The nurse maintains eye contact; both nurse and client are seated. 5. During the interview, the nurse asks if the client is currently experiencing any pain or anxiety before proceeding further. Correct Answer: 1,2,3 Rationale 1: The nurse has requested that the client put on a cotton gown prior to the interview. Thin cotton examining gowns often make the older client feel uncomfortably chilly and less able to attend to the health history questions. The nurse could provide the client with a robe or wait to request that the client put on a robe until following the interview. Rationale 2: The nurse seats the client so that the light from the window faces the client with the nurse’s back to the window. The client should have her back to the window or strong light source. Thus glare is reduced, and the light falls upon the face of the examiner. Rationale 3: The nurse addresses the client by her first name. The nurse should address the client by her last name until the client states that it is appropriate to be more informal. Rationale 4: The nurse maintains eye contact; both nurse and client are seated. The nurse should maintain good eye contact during the interview and assessment. The nurse and client should be able to communicate at eye level. Rationale 5: During the interview, the nurse asks if the client is currently experiencing any pain or anxiety before proceeding further. The nurse should assess the client’s level of pain and anxiety to ensure that the client does not require pain medication or an intervention prior to continuing with the interview and assessment. Global Rationale: Thin cotton examining gowns often make the older client feel uncomfortably chilly and less able to attend to the health history questions. The nurse could provide the client with a robe or wait to request that the client put on a robe until following the interview. The client should have her back to the window or strong light source. Thus glare is reduced, and the light falls upon the face of the examiner. The nurse should address the client by her last name until the client states that it is appropriate to be more informal. The nurse should maintain good eye contact during the interview and assessment. The nurse and client should be able to communicate at eye level. The nurse should assess the client’s level of pain and anxiety to ensure that the client does not require pain medication or an intervention prior to continuing with the interview and assessment. Cognitive Level: Applying

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.3: Describe techniques required to assess older adults. Question 13 Type: FIB The nurse is using the Katz Index of Independence in Activities of Daily Living tool to assess the client’s level of independence. Based on the table below, calculate the client’s total number of points. points

Standard Text: Correct Answer: 3 points Rationale : Global Rationale: Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.3: Describe techniques required to assess older adults. Question 14 Type: MCSA The nurse is preparing to perform an evaluation of the older adult client’s level of cognitive reasoning. The student nurse is observing. Which of the following statements by the student nurse indicates the need for further education? 1. “The Mini–Mental State Examination seems like a quick way to determine how well the client is able to reason.” 2. “It’s best to go ahead and give the Mini–Mental State Examination at the beginning of the focused interview because the client’s mind will be fresh.” 3. “It sounds like some older people get really nervous about these cognitive reasoning examinations because they worry they may be developing problems.” 4. “The Mini–Mental State Examination is really easy to perform so it’s important to remember that the client may have just gone through these types of questions the day before with another healthcare provider.” Correct Answer: 2 Rationale 1: The Mini–Mental State Examination is one screening instrument of cognitive reasoning that has been used extensively for 30 years. It is familiar to most practitioners and rates well as a reliable and valid tool for detecting dementia and delirium relating to organic disease.The Mini–Mental State Examination is easy to use. It takes less than 10 minutes to administer and requires no special testing materials other than paper and pencil. Rationale 2: The nurse should wait to develop rapport with the older adult client prior to performing a cognitive reasoning examination. The nurse should not perform this assessment at the beginning of the focused interview. The screening should be done toward the end of the verbal part of the interview, when the client has learned to feel comfortable with the interviewer and a rapport has developed. Rationale 3: Older clients who take the test on a periodic basis begin to learn the scoring system and keep track of their scores. They may become fearful of this progression of numbers and resist giving an opportunity for comparison if they feel it will show decline. Rationale 4: One problem with the Mini–Mental State Examination is that it is so widely used that clients may become irritated when they find themselves taking the test over and over. It also becomes easy for anyone, young or old, with dementia or not, to become confused between the answers on one test and the next when they are given too close together. Global Rationale: The Mini–Mental State Examination is one screening instrument of cognitive reasoning that has been used extensively for 30 years. It is familiar to most practitioners and rates well as a reliable and valid tool for detecting dementia and delirium relating to organic disease. The nurse should wait to develop rapport with the older adult client prior to performing a cognitive reasoning examination. The nurse should not perform this

assessment at the beginning of the focused interview. The screening should be done toward the end of the verbal part of the interview, when the client has learned to feel comfortable with the interviewer and a rapport has developed. The Mini–Mental State Examination is easy to use. It takes less than 10 minutes to administer and requires no special testing materials other than paper and pencil. Older clients who take the test on a periodic basis begin to learn the scoring system and keep track of their scores. They may become fearful of this progression of numbers and resist giving an opportunity for comparison if they feel it will show decline. One problem with the Mini–Mental State Examination is that it is so widely used that clients may become irritated when they find themselves taking the test over and over. It also becomes easy for anyone, young or old, with dementia or not, to become confused between the answers on one test and the next when they are given too close together. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.3: Describe techniques required to assess older adults. Question 15 Type: MCMA The nurse is performing a focused interview with an older adult client. Which of the following statements indicate the client has an increased risk of developing depression? Standard Text: Select all that apply. 1. “I’ve been so lonely since my wife, Maggie, passed away 2 months ago.” 2. “My mother had a history of depression.” 3. “I was diagnosed with chronic bronchitis 4 years ago.” 4. “My son visits at least once a week and takes care of my financial stuff.” 5. “I visit my sister every Monday and she makes me dinner.” Correct Answer: 1,2,3 Rationale 1: “I’ve been so lonely since my wife, Maggie, passed away 2 months ago.” Loneliness is a risk factor for the development of depression. Rationale 2: “My mother had a history of depression.” A family history of depression increases the client’s risk. Rationale 3: “I was diagnosed with chronic bronchitis 4 years ago.” Chronic illnesses such as chronic bronchitis increases the client’s risk for becoming depressed. Rationale 4: “My son visits at least once a week and takes care of my financial stuff.” This client’s son visits. The client has evidence of a social support system.

Rationale 5: “I visit my sister every Monday and she makes me dinner.” The client visits a sibling each week and shares a meal with the sibling. This is more evidence of the presence of a social support system. Global Rationale: Loneliness is a risk factor for the development of depression. A family history of depression increases the client’s risk. Chronic illnesses such as chronic bronchitis increases the client’s risk for becoming depressed. This client’s son visits. The client has evidence of a social support system. The client visits a sibling each week. This is more evidence of the presence of a social support system. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.3: Describe techniques required to assess older adults. Question 16 Type: SEQ The nurse is assessing the older adult client who has been admitted to the hospital following a fall. The nurse is using the Fulmer SPICES framework to assess the client for predicting and preventing problems that the client may experience. Rank the following assessment questions by the nurse in order of occurrence based on this framework. Standard Text: Click and drag the options below to move them up or down. Choice 1. “Do you have any concerns about your memory?” Choice 2. “It looks like you’ve lost some weight since your healthcare provider last saw you. How are your teeth?” Choice 3. “Can you tell me about how well you are sleeping?” Choice 4. “Have you had any problems holding your urine?” Choice 5. “I noticed that you have a large bruise on your knee. Did you fall recently?” Correct Answer: 3,2,4,5,1 Rationale 1: The first thing to assess is how well the client is sleeping. The nurse needs to determine if the client may be experiencing any sleep disorders. Rationale 2: The second thing is for the nurse to determine if the client is having any difficulty eating or feeding him or herself. Rationale 3: The third thing is for the nurse to determine if the client is experiencing any difficulties with incontinence. Rationale 4: The nurse must then assess for any clinical manifestations of confusion. Following that, the nurse can assess for any evidence that the client has fallen.

Rationale 5: The last thing is for the nurse to assess for any evidence of skin breakdown. Global Rationale: The correct order to perform the Fulmer SPICES assessment framework is as follows: S Sleep Disorders P Problems with eating and feeding I Incontinence C Confusion E Evidence of falls S Skin Breakdown Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.3: Describe techniques required to assess older adults. Question 17 Type: MCMA The nurse is performing a focused interview with an elderly client. The client says, “My mouth is always so dry. Sometimes, I feel like my tongue has grooves in it.” The nurse inspects the client’s tongue and discovers that it is red and dry with the presence of furrows. Based on the client’s most likely condition, the nurse expects to learn which of the following? Standard Text: Select all that apply. 1. Serum glucose level is 232 mg/dL. 2. White blood cells 32,000 mm3. 3. The client states, “I take Lasix every morning because I have some heart problems.” 4. The client states, “I have diabetes but I don’t check my blood sugar levels as often as I should.” 5. Platelets 92,000 mm3. Correct Answer: 1,3,4 Rationale 1: Serum glucose level is 232 mg/dL. A dry and red tongue with longitudinal furrows may indicate dehydration in the elderly especially in people taking diuretics or having elevated blood sugar levels. This client’s serum glucose level is elevated. Rationale 2: White blood cells 32,000 mm3. The client’s white blood cell count is elevated. This is an unexpected finding. This indicates that the client has an infection. A dry and red tongue with longitudinal furrows may indicate dehydration in the elderly especially in people taking diuretics or having elevated blood sugar levels.

Rationale 3: The client states, “I take Lasix every morning because I have some heart problems.” A dry and red tongue with longitudinal furrows may indicate dehydration in the elderly especially in people taking diuretics or having elevated blood sugar levels. The client takes a diuretic each day. Rationale 4: The client states, “I have diabetes but I don’t check my blood sugar levels as often as I should.” The client has diabetes but admittedly does not monitor serum glucose levels as frequently as recommended. Rationale 5: Platelets 92,000 mm3. The client’s platelet level is decreased. This is an unexpected finding. A dry and red tongue with longitudinal furrows may indicate dehydration in the elderly especially in people taking diuretics or having elevated blood sugar levels. Global Rationale: A dry and red tongue with longitudinal furrows may indicate dehydration in the elderly, especially in people taking diuretics or having elevated blood sugar levels. This client’s serum glucose level is elevated. The client takes a diuretic each day. The client has diabetes but admittedly does not monitor serum glucose levels as frequently as recommended. The client’s white blood cell count is elevated. This is an unexpected finding. The client’s platelet level is decreased. This is an unexpected finding. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 18 Type: MCSA The nurse is examining the eyes of an elderly client using the ophthalmoscope. The vessels of the eyes are narrow and tapered in appearance. The nurse would correctly choose which of the following actions? 1. Document the findings as normal. 2. Assess the pupils to determine if they equal, round, reactive to light, and accommodation. 3. Inquire about any past history of hypertension. 4. Inquire about a history of diabetes. Correct Answer: 3 Rationale 1: These are abnormal findings. Narrowing and tapering of the arterioles are abnormal findings and are seen in clients with a history of hypertension. The nurse must obtain additional information about a previous diagnosis of hypertension. Rationale 2: The assessment of PERRLA is not necessary at this time. The nurse must obtain additional information about a previous diagnosis of hypertension.

Rationale 3: Narrowing and tapering of the arterioles are abnormal findings and are seen in clients with a history of hypertension. The nurse must obtain additional information about a previous diagnosis of hypertension. Rationale 4: The vessels in diabetic retinopathy display small, red spots or creamy, round lesions that indicate punctate hemorrhages. Global Rationale: Narrowing and tapering of the arterioles are abnormal findings and are seen in clients with a history of hypertension. The nurse must obtain additional information about a previous diagnosis of hypertension. These are abnormal findings. The assessment of PERRLA is not necessary at this time. The vessels in diabetic retinopathy display small, red spots or creamy, round lesions that indicate punctate hemorrhages. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 19 Type: MCMA The nurse is performing a head-to-toe assessment on an older adult client who was admitted to the hospital with dehydration. Which of the following findings are consistent with this condition? Standard Text: Select all that apply. 1. Tenting noted on dorsal aspect of client’s hand when skin turgor was assessed. 2. Client has produced 175 milliliters over the last 8 hours. 3. Dentures are loose, small sores noted in oral mucosa. 4. Healthcare provider notes client exhibiting xerostomia. 5. Client’s apical heart rate is 82 beats per minute. Correct Answer: 2,3,4 Rationale 1: Tenting noted on dorsal aspect of client’s hand when skin turgor was assessed. Tenting is not an appropriate way to monitor for dehydration in the older adult client due to loss of skin elasticity. Rationale 2: Client has produced 175 milliliters over the last 8 hours. The client is not producing an adequate amount of urine, which may indicate the client is dehydrated. The client should have produced at least 240 milliliters over the last 8 hours. Rationale 3: Dentures are loose, small sores noted in oral mucosa. The client with loosely fitting dentures and sores on the oral mucosa may be experiencing dehydration.

Rationale 4: Healthcare provider notes client exhibiting xerostomia. The client with xerostomia is not producing saliva and this can be associated with dehydration. Rationale 5: Client’s apical heart rate is 82 beats per minute. The client’s heart rate is within normal limits and does not indicate that the client is dehydrated. Global Rationale: The client is not producing an adequate amount of urine, which may indicate the client is dehydrated. The client should have produced at least 240 milliliters over the last 8 hours. The client with loosely fitting dentures and sores on the oral mucosa may be experiencing dehydration. The client with xerostomia is not producing saliva and this can be associated with dehydration. Tenting is not an appropriate way to monitor for dehydration in the older adult client due to loss of skin elasticity. The client’s heart rate is within normal limits and does not indicate that the client is dehydrated. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 20 Type: MCMA The older adult male client is visiting the outpatient clinic. During the focused interview, the client admits that he is experiencing clinical manifestations associated with erectile dysfunction. Which of the following statements by the client indicate that the client may be taking a medication that could produce this problem? Standard Text: Select all that apply. 1. “I take something to help my stomach not make so much acid.” 2. “I’ve been taking something for depression ever since our son died 4 years ago.” 3. “Sometimes, I have to take a medication to help me sleep at night.” 4. “I’ve had trouble with my blood pressure for years and take a medication to keep it down.” 5. “I take a baby aspirin every day.” Correct Answer: 2,3,4 Rationale 1: “I take something to help my stomach not make so much acid.” Proton-pump inhibitiors and histamine-2 blockers have not been associated with erectile dysfunction. Rationale 2: “I’ve been taking something for depression ever since our son died 4 years ago.” Medications that may cause erectile dysfunction include antidepressants such as serotonin reuptake inhibitors, monoamine oxidase inhibitors, and tricyclic antidepressants.

Rationale 3: “Sometimes, I have to take a medication to help me sleep at night.” Clients who take tranquilizers have an increased risk of experiencing erectile dysfunction. Rationale 4: “I’ve had trouble with my blood pressure for years and take a medication to keep it down.” Clients who take antihypertensives have an increased risk of experiencing erectile dysfunction. Rationale 5: “I take a baby aspirin every day.” Aspirin is not associated with erectile dysfunction. Global Rationale: Medications that may cause erectile dysfunction include antidepressants such as serotonin reuptake inhibitors, monoamine oxidase inhibitors, and tricyclic antidepressants. Clients who take tranquilizers have an increased risk of experiencing erectile dysfunction. Clients who take antihypertensives have an increased risk of experiencing erectile dysfunction. Proton-pump inhibitiors and histamine-2 blockers have not been associated with erectile dysfunction. Aspirin is not associated with erectile dysfunction. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 21 Type: MCSA The nurse is examining the eyes of an elderly client using the ophthalmoscope. The vessels of the eyes are narrow and straight in appearance. The nurse would correctly choose which of the following actions? 1. Obtain an ophthalmology referral. 2. Inquire to determine if the client has any risk factors for glaucoma. 3. Inquire to determine if the client has a history of diabetes. 4. Document the findings as normal. Correct Answer: 4 Rationale 1: Since this is a normal finding based on the client’s age, the nurse does not need to attempt to obtain an ophthalmology referral. Rationale 2: The client is not exhibiting signs of glaucoma. “Cupping” of the disc is a sign of glaucoma. Rationale 3: Small red spots or creamy round lesions are punctate hemorrhages and exudate seen in diabetic retinopathy. Rationale 4: Age-related changes in the eyes include the presence of narrower and straighter vessels, which should be documented as a normal finding.

Global Rationale: Age-related changes in the eyes include the presence of narrower and straighter vessels, which should be documented as a normal finding. Since this is a normal finding based on the client’s age, the nurse does not need to attempt to obtain an ophthalmology referral. The client is not exhibiting signs of glaucoma. “Cupping” of the disc is a sign of glaucoma. The client is not exhibiting signs of diabetes. Small red spots or creamy round lesions are punctate hemorrhages and exudate seen in diabetic retinopathy. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 22 Type: MCSA The nurse is assessing an 84-year-old client. The nurse notes the presence of edema in both knees and ankles. The client complains of joint stiffness and pain upon awakening. The nurse would suspect which of the following disorders? 1. Bursitis 2. Gouty arthritis 3. Osteoarthritis 4. Rheumatoid arthritis Correct Answer: 3 Rationale 1: Bursitis produces heat, redness, swelling, and pain with movement of the joints. Rationale 2: Gouty arthritis produces heat, redness, swelling, and pain with movement of the joints. Rationale 3: Osteoarthritis causes swelling and joint deformity with early morning stiffness and pain. Rationale 4: Rheumatoid arthritis produces heat, redness, swelling, and pain with movement of the joints, but is more likely to be seen in younger adults. Global Rationale: Osteoarthritis causes swelling and joint deformity with early morning stiffness and pain. Bursitis and gouty arthritis produce heat, redness, swelling, and pain with movement of the joints. Rheumatoid arthritis produces heat, redness, swelling, and pain with movement of the joints, but is more likely to be seen in younger adults. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 23 Type: MCSA The nurse is assessing the elderly client’s respiratory system. Upon auscultation, rales are detected bilaterally in both lower lobes. Scattered rales are heard in the upper lung fields. These adventitious sounds do not clear with a cough. The nurse percusses the client’s lung fields and determines the presence of dull sounds. The nurse would correctly suspect which of the following? 1. Emphysema 2. Pulmonary edema 3. End-stage chronic obstructive pulmonary disease 4. Pulmonary fibrosis Correct Answer: 2 Rationale 1: Emphysema produces diminished breath sounds. Rationale 2: Rales that extend upward and do not clear with cough suggest pulmonary edema. Dullness indicates fluid accumulation from pulmonary edema. Rationale 3: The absence of breath sounds, harsh rhonchi, or bronchovesicular breath sounds in the periphery are indicative of advanced chronic lung disease. Rationale 4: Coarse, loud rales may be signs of pulmonary fibrosis and are usually found in clients with longstanding lung disease. Global Rationale: Rales that extend upward and do not clear with cough suggest pulmonary edema. Dullness indicates fluid accumulation from pulmonary edema. Emphysema produces diminished breath sounds. The absence of breath sounds, harsh rhonchi, or bronchovesicular breath sounds in the periphery are indicative of advanced chronic lung disease. Coarse, loud rales may be signs of pulmonary fibrosis and are usually found in clients with longstanding lung disease. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 24 Type: MCSA

The daughter of an elderly client reports that the client is experiencing a decrease in hearing ability in the client’s right ear. The nurse suspects a conductive hearing loss due to the presence of dried wax in the right ear canal. In which of the following ways can the nurse best validate this suspicion? 1. Perform the Weber test. 2. Perform the Rinne test. 3. Examine the external ear. 4. Perform the whisper test. Correct Answer: 1 Rationale 1: Excessive cerumen may cause a conductive hearing loss in the elderly due to cerumen dryness and an inability to remove the cerumen properly. The Weber test can validate this finding by showing sound lateralizing to the left ear. Rationale 2: The Rinne test is used to validate sensorineural hearing loss, which normally demonstrates that air conduction is greater than bone conduction. The Weber test can validate the nurse’s finding by showing sound lateralizing to the left ear. Rationale 3: Performing the whisper test is not a relevant action at this time. The Weber test can validate the nurse’s finding by showing sound lateralizing to the left ear. Rationale 4: Earwax cannot always be visualized by external ear examination. The Weber test can validate the nurse’s finding by showing sound lateralizing to the left ear. Global Rationale: Excessive cerumen may cause a conductive hearing loss in the elderly due to cerumen dryness and an inability to remove the cerumen properly. The Weber test can validate this finding by showing sound lateralizing to the left ear. The Rinne test is used to validate sensorineural hearing loss, which normally demonstrates that air conduction is greater than bone conduction. Performing the whisper test is not a relevant action at this time, and earwax cannot always be visualized by external ear examination. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 25 Type: MCSA The nurse hears a bruit when auscultating the right carotid artery of an elderly client. The nurse would choose which of the following actions next? 1. Auscultate the heart for murmurs.

2. Obtain a surgical consult. 3. Document the findings as normal. 4. Assess for jugular vein distention. Correct Answer: 1 Rationale 1: Bruits are abnormal signs of carotid stenosis and may signal an impending stroke. If a bruit is heard, auscultation of the aortic and pulmonic valves of the heart should be done to assess for murmurs that may be radiating into the neck. This is essential additional assessment data. Rationale 2: There is no reason to obtain a surgical consult at this stage. The nurse should auscultate the aortic and pulmonic valves of the heart for the presence of murmurs. Murmurs may radiate into the client’s neck. Rationale 3: The findings are abnormal. Rationale 4: The nurse should assess for jugular venous distention during the head-to-toe assessment. However, after hearing a bruit over the client’s right carotid artery, the nurse must auscultate the heart for the presence of murmurs. Global Rationale: Bruits are abnormal signs of carotid stenosis and may signal an impending stroke. If a bruit is heard, auscultation of the aortic and pulmonic valves of the heart should be done to assess for murmurs that may be radiating into the neck. This is essential additional assessment data. There is no reason to obtain a surgical consult, at this stage. The nurse should auscultate the aortic and pulmonic valves of the heart for the presence of murmurs. Murmurs may radiate into the client’s neck. The findings are abnormal. The nurse should assess for jugular venous distention during the head-to-toe assessment, but at this point the nurse must auscultate the heart for the presence of murmurs. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 26 Type: MCSA The nurse is assessing the vital signs of an elderly client and obtains a temperature of 97.1 degrees Fahrenheit. Which of the following actions is most appropriate? 1. Document the finding as normal. 2. Encourage the client to drink warm fluids. 3. Request to turn up the client’s thermostat.

4. Apply warmed blankets to the client. Correct Answer: 1 Rationale 1: The body temperature in older adults is lower than that of younger clients. The mean temperature is 36.2 degrees Centigrade (97.2 degrees Fahrenheit). The temperature described is within normal limits for an elderly client. Rationale 2: There is no need to encourage the client to drink warm fluids. The temperature described is within normal limits for an elderly client. Rationale 3: There is no reason to request to turn up the client’s thermostat. The temperature described is within normal limits for an elderly client. Rationale 4: There is no reason to apply warmed blankets to the client. The temperature described is within normal limits for an elderly client. Global Rationale: The body temperature in older adults is lower than that of younger clients. The mean temperature is 36.2 degrees Centigrade (97.2 degrees Fahrenheit). The temperature described is within normal limits for an elderly client. There is no need to encourage the client to drink warm fluids. There is no reason to turn up the client’s thermostat. There is no reason to apply warmed blankets to the client. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 27 Type: MCSA The nurse is performing a focused interview with an elderly client. The client reports the presence of painful sores. The client states, “They wrap around in lines from my back toward my belly.” During the assessment of the client’s skin, the nurse discovers the sores are reddened vesicles. The nurse would suspect which of the following conditions? 1. Ecchymoses 2. Herpes zoster 3. Petechiae 4. Purpura Correct Answer: 2

Rationale 1: Ecchymoses are bruises. The nurse’s findings are most consistent with the development of herpes zoster. Rationale 2: Herpes zoster is also commonly called shingles. Herpes zoster is more common in older adults. The nurse should look for painful, red vesicular or pustular lesions that may be in a line or in patches on the thorax or abdomen. Rationale 3: Petechiae are small areas where bleeding has occurred under the skin. The nurse’s findings are most consistent with the development of herpes zoster. Rationale 4: Purpura is a reddish or purplish area that does not blanch when pressure is applied. The nurse’s findings are most consistent with the development of herpes zoster. Global Rationale: Herpes zoster is also commonly called shingles. Herpes zoster is more common in older adults. The nurse should look for painful, red vesicular or pustular lesions that typically follow a linear pattern. Common sites are the thorax or abdomen. Ecchymoses are bruises. Petechiae are small areas where bleeding has occurred under the skin. Purpura is a reddish or purplish area that does not blanch when pressure is applied. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 28 Type: MCSA The nurse is conducting a focused interview with an elderly client. The client states that she is concerned about “All of these little bumps on my neck and chest.” Moist, brownish, wart-like lesions are noted on the neck and chest. The nurse would suspect which of the following conditions? 1. Cherry angiomas 2. Acrochordons 3. Actinic keratoses 4. Seborrhea keratoses Correct Answer: 4 Rationale 1: Cherry angiomas are vascular lesions that produce tiny, red spots usually on the trunk. Rationale 2: They are pedunculated, flesh-colored lesions that occur on the neck, back, axillary area, and eyelids. Rationale 3: Actinic keratoses are normal aging growths that appear as callus-like red, yellow, or flesh-colored plaques appearing on exposed areas such as ears, cheeks, lips, nose, upper extremities, or balding scalp.

Rationale 4: Seborrhea keratoses are benign, greasy, wart-like lesions that are yellow-brown in color. They commonly appear of the neck, chest, and back. Global Rationale: Seborrhea keratoses are benign, greasy, wart-like lesions that are yellow-brown in color. They commonly appear of the neck, chest, and back. Cherry angiomas are vascular lesions that produce tiny, red spots usually on the trunk. Acrochordons are also called skin tags. They are pedunculated, flesh-colored lesions that occur on the neck, back, axillary area, and eyelids. Actinic keratoses are normal aging growths that appear as callus-like red, yellow, or flesh-colored plaques appearing on exposed areas such as ears, cheeks, lips, nose, upper extremities, or balding scalp. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 29 Type: MCMA The nurse is examining the oral cavity of an elderly client with complaints of mouth soreness. Red, cracked skin is noted at each corner of the mouth. Which of the following findings is most consistent with this client’s condition? Standard Text: Select all that apply. 1. The client states, “I have an appointment next week to get some better fitting dentures.” 2. Red blood cell count is 6.2 million/ mm3. 3. The healthcare provider has diagnosed the client with cheilitis. 4. The client suffered from a cerebrovascular accident last May. 5. The result of the culture of the drainage is that candida albicans is present. Correct Answer: 1,3,4,5 Rationale 1: The client states, “I have an appointment next week to get some better fitting dentures.” Cheilitis may also be called angular stomatitis. Cheilitis is seen in persons with poorly fitting dentures. Rationale 2: Red blood cell count is 6.2 million/ mm3. The client’s red blood cell count is elevated. This is not necessarily associated with the development of cheilitis. Rationale 3: The healthcare provider has diagnosed the client with cheilitis. The nurse would not be surprised to learn that the healthcare provider diagnosed the condition as cheilitis.

Rationale 4: The client suffered from a cerebrovascular accident last May. Clients who have a history of a stroke have an increased risk of developing cheilitis because they may be unable to swallow well. Rationale 5: The result of the culture of the drainage is that candida albicans is present. Cheilitis can be caused by candida infection. Global Rationale: Cheilitis may also be called angular stomatitis. Cheilitis is seen in persons with poorly fitting dentures. The nurse would not be surprised to learn that the healthcare provider diagnosed the condition as cheilitis. Clients who have a history of a stroke have an increased risk of developing cheilitis because they may be unable to swallow well. Cheilitis can be caused by candida infection. The client’s red blood cell count is elevated. This is not necessarily associated with the development of cheilitis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 30 Type: MCSA During the assessment of a 66-year-old client’s apical pulse, the nurse notes the presence of a faint murmur. The nurse documents that a grade 3 murmur can be auscultated without radiation. The client denies ever having been diagnosed with any heart problems. Based upon your knowledge, which of the following statements is most correct? 1. The client is demonstrating mitral calcifications. 2. The client has valvular stenosis. 3. The client is presenting with the normal changes of aging. 4. The client has clinical manifestations associated with aortic calcifications. Correct Answer: 3 Rationale 1: Clicks and snaps can be associated with mitral calcifications. Rationale 2: Loud murmurs grade 4 or greater with thrills or radiation can be associated with valvular stenosis. Rationale 3: Grade 3 murmurs without radiation are commonly present in older people because of decreased cardiac muscle tone. Rationale 4: Clicks and snaps can be associated with aortic calcifications. Global Rationale: Grade 3 murmurs without radiation are commonly present in older people because of decreased cardiac muscle tone. Clicks and snaps can be associated with mitral calcifications. Loud murmurs grade

4 or greater with thrills or radiation can be associated with valvular stenosis. Clicks and snaps can be associated with aortic calcifications. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 31 Type: MCSA The client is visiting the outpatient clinic for a routine blood pressure assessment. While speaking with the nurse, the client states, “I’m getting old and everything hurts.” Which statement or question by the nurse is most appropriate? 1. “Tell me more about your pain.” 2. “Normal aging can be quite painful.” 3. “You must have osteoarthritis.” 4. “What medications do you take?” Correct Answer: 1 Rationale 1: Reports of pain should never be dismissed as a normal part of aging. The pain reports made by a client need to be investigated. The nurse will need to ask more questions about the client’s pain to obtain additional assessment data. Rationale 2: Normal aging is not always necessarily painful. Rationale 3: It is inappropriate and beyond the scope of practice of the nurse to make a medical diagnosis. Rationale 4: Asking about pharmacological therapies is a part of the assessment. However, the best question for the nurse to ask the client at this time is regarding the client’s pain. Global Rationale: Reports of pain should never be dismissed as a normal part of aging. The pain reports made by a client need to be investigated. The nurse will need to ask more questions about the client’s pain to obtain additional assessment data. Normal aging is not always necessarily painful. It is inappropriate and beyond the scope of practice of the nurse to make a medical diagnosis. Asking about pharmacological therapies is a part of the assessment. However, the best question for the nurse to ask the client at this time is regarding the client’s pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 32 Type: MCSA A 76-year-old client presents to the outpatient clinic with complaints consistent with influenza. During the interaction, the nurse notes the client’s clothing appears too large. Which of the following actions by the nurse should be performed first? 1. Document the findings. 2. Report the findings to the healthcare provider. 3. Contact social services. 4. Engage the client in a discussion regarding dietary practices. Correct Answer: 4 Rationale 1: The findings must be documented but should be done after the interaction is finished. The nurse needs to determine the reason for the client’s weight loss by conversing with the client. Rationale 2: At this point, there is no need to consult with the healthcare provider. The nurse needs to determine the reason for the client’s weight loss by conversing with the client. Rationale 3: At this point, there is no need to contact social services. The nurse needs to determine the reason for the client’s weight loss by conversing with the client. Rationale 4: Baggy clothing may be reflective of recent weight loss. Obtaining information needed to assess for nutritional problems and dietary practices can best be assessed by conversation between the client and nurse. Global Rationale: Baggy clothing may be reflective of recent weight loss. Obtaining information needed to assess for nutritional problems and dietary practices can best be assessed by conversation between the client and nurse. The findings must be documented but should be done after the interaction is finished. At this point, there is no need to consult with the healthcare provider. At this point, there is no need to contact social services. The nurse needs to determine the reason for the client’s weight loss by conversing with the client. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 33 Type: MCSA

While performing an integumentary assessment on a 72-year-old male client, the nurse notes the presence of tenting. Which of the following actions is indicated by the nurse first? 1. The nurse will need to notify the healthcare provider. 2. The rate of the intravenous infusion will need to be increased to combat dehydration. 3. A lung assessment will need to be performed. 4. No action is indicated. Correct Answer: 4 Rationale 1: There is no need to notify the healthcare provider. The lack of skin turgor in an older client is a normal finding. Rationale 2: It is beyond the nursing scope of practice for the nurse to independently alter the rate of the intravenous infusion of fluids. Rationale 3: A lung assessment is not needed in relation to this client’s clinical presentation. Rationale 4: The lack of skin turgor in an older client is a normal finding. This is due to the reduction in elasticity of the skin. Global Rationale: The lack of skin turgor in an older client is a normal finding. This is due to the reduction in elasticity of the skin. There is no need to notify the healthcare provider. It is beyond the nursing scope of practice for the nurse to independently alter the rate of the intravenous infusion of fluids. A lung assessment is not needed in relation to this client’s clinical presentation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult. Question 34 Type: MCSA The nurse is counseling an elderly couple and encourages both of them to receive the pneumococcal vaccine. The nurse would understand that further teaching is necessary if which of the following statements was made by one of the clients? 1. “We will need to get vaccinated each year.” 2. “The vaccine is recommended for us because we are both over the age of 65.” 3. “The vaccine does not protect us against all types of pneumonia.”

4. “We should get the influenza vaccine and the pneumonia vaccine.” Correct Answer: 1 Rationale 1: Although it was originally considered that the vaccine would give once-a-lifetime immunization, the Centers for Disease Control and Prevention now recommends that boosters be given to those people who received their initial immunization more than 5 years ago. It is not administered each year. People should receive the influenza vaccine each year. Rationale 2: The pneumonia vaccine is recommended for clients over the age of 65. Rationale 3: The vaccine protects against 23 types of infections that cause 85% to 90% of all cases of pneumonia in the United States. Rationale 4: It is important for the older adult to obtain vaccinations against influenza and pneumonia. These two diseases together constitute the fourth leading cause of death in people older than 65 years. Global Rationale: Although it was originally considered that the vaccine would give once-a-lifetime immunization, the Centers for Disease Control and Prevention now recommends that boosters be given to those people who received their initial immunization more than 5 years ago. It is not administered each year. People should receive the influenza vaccine each year. The pneumococcal vaccine is recommended for clients over the age of 65. The vaccine protects against 23 types of infections that cause 85% to 90% of all cases of pneumonia in the United States. It is important for the older adult to obtain vaccinations against influenza and pneumonia. These two diseases together constitute the fourth leading cause of death in people older than 65 years. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.5: Discuss the objectives in Healthy People 2020 for older adults. Question 35 Type: MCSA The nurse is planning an educational program for new nurses regarding healthcare needs of the elderly. Which of the following should be included? 1. Depression is not a common problem for the elderly. 2. Influenza vaccines should be given to most elderly clients. 3. Burns are the most common type of injuries experienced by older adults. 4. Pneumonia is the most common cause of death in older adults. Correct Answer: 2

Rationale 1: Depression is a common issue for older adults. Depression is often related to the presence of serious health disorders, financial concerns, and isolation. Rationale 2: Influenza vaccines are recommended for the majority of older adults. Rationale 3: Falls, not burns, are the most common injuries for older adults. Seniors who suffer hip fractures are often never able to live independently after the incident. Rationale 4: Pneumonia is not the most common cause of death, but it is in the top 10. Global Rationale: Influenza vaccines are recommended for the majority of older adults. Depression is a common issue for older adults. Depression is often related to the presence of serious health disorders, financial concerns, and isolation. Falls, not burns, are the most common injuries for older adults. Seniors who suffer hip fractures are often never able to live independently after the incident. Pneumonia is not the most common cause of death, but it is in the top 10. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.5: Discuss the objectives in Healthy People 2020 for older adults. Question 36 Type: MCSA During a routine physical examination, a client reports a close relative recently died from complications related to heart disease. The client requests information about her own risk for the development of heart disease. The nurse reviews the client’s risk factors for the development of the disease. Which of the following risk factors associated with heart disease is modifiable? 1. Father died from coronary artery disease. 2. Client is 5′4″ and weighs 282 pounds. 3. Client is 73 years old. 4. Client is a female. Correct Answer: 2 Rationale 1: Modifiable risk factors are those over which the client has some degree of control. Family history is a nonmodifiable risk factor. Rationale 2: Modifiable risk factors are those over which the client has some degree of control. Obesity is a modifiable risk factor. Rationale 3: Modifiable risk factors are those over which the client has some degree of control. Age is a nonmodifiable risk factor.

Rationale 4: Modifiable risk factors are those over which the client has some degree of control. Gender is a nonmodifiable risk factor. Global Rationale: Modifiable risk factors are those over which the client has some degree of control. Family history is a nonmodifiable risk factor. Age is a nonmodifiable risk factor. Gender is a nonmodifiable risk factor. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.5: Discuss the objectives in Healthy People 2020 for older adults. Question 37 Type: MCMA The nurse is educating a client who has been diagnosed with stress incontinence. The nurse should include which of the following in the teaching care plan? Standard Text: Select all that apply. 1. The client should maintain an ideal body weight. 2. The client should limit fluid intake to 4 glasses a day. 3. The client should try to void on a regular schedule. 4. The client should perform pelvic muscle strengthening exercises. 5. The client should increase fiber intake. Correct Answer: 1,3,4 Rationale 1: The client should maintain an ideal body weight. The client should maintain an ideal body weight. Obesity is associated with stretching of perineal muscles and further contributes to stress incontinence in females. Rationale 2: The client should limit fluid intake to four glasses a day. Limiting fluid to 4 glasses each day is not recommended. Fluid intake should include 8 to 10 glasses of decaffeinated fluid each day. Rationale 3: The client should try to void on a regular schedule. The client should void on a regular schedule. Sometimes, when older adults are tired they are more likely to experience periods of incontinence. Voiding on a regular schedule can help prevent accidents when the client is fatigued. Rationale 4: The client should perform pelvic muscle strengthening exercises. Pelvic muscle strengthening exercises can strengthen the muscles that are used to prevent incontinence. Rationale 5: The client should increase fiber intake. Increasing fiber intake is recommended for elderly clients because it may help with constipation but will not help the client with stress incontinence.

Global Rationale: The client should maintain an ideal body weight. Obesity is associated with stretching of perineal muscles and further contributes to stress incontinence in females. The client should void on a regular schedule. Sometimes, when older adults are tired they are more likely to experience periods of incontinence. Voiding on a regular schedule can help prevent accidents when the client is fatigued. Pelvic muscle-strengthening exercises can strengthen the muscles that are used to prevent incontinence. Limiting fluid to 4 glasses each day is not recommended. Fluid intake should include 8 to 10 glasses of decaffeinated fluid each day. The client should try limiting intake only during the evening hours. Increasing fiber intake may help with constipation but will not help the client with stress incontinence. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.6: Apply critical thinking in a selected simulated situation related to the care of the older adult. Question 38 Type: MCMA The older adult client had been experiencing nocturia and decided to voluntarily restrict fluid intake during the day to help avoid the problem. Which of the following statements by the client’s daughter indicates that the client may be experiencing a complication associated with this practice? Standard Text: Select all that apply. 1. “He fell and hit his head because he’s been so unsteady.” 2. “His stools have started to look loose and bloody.” 3. “I think he’s beginning to develop Alzheimer’s disease because he can get so confused.” 4. “I don’t think he’s had a bowel movement since 1 week ago.” 5. “His urine looks cloudy and dark.” Correct Answer: 1,3,4,5 Rationale 1: “He fell and hit his head because he’s been so unsteady.” This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. Dehydration may lead to an increased fall risk because dehydration may alter the client’s electrolyte status, leaving him weak and tired. This will increase the client’s risk of falling. Rationale 2: “His stools have started to look loose and bloody.” This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. Loose and bloody stools are not typically associated with dehydration.

Rationale 3: “I think he’s beginning to develop Alzheimer’s disease because he can get so confused.” This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. Dehydration can result in confusion. Rationale 4: “I don’t think he’s had a bowel movement since 1 week ago.” This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. Dehydration can result in constipation. Rationale 5: “His urine looks cloudy and dark.” This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. The client who is suffering from dehydration may experience urinary tract infections. His urine may look dark and cloudy. Global Rationale: This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. Dehydration may lead to an increased fall risk because dehydration may alter the client’s electrolyte status, leaving him weak and tired. This will increase the client’s risk of falling. Dehydration can result in confusion. Dehydration can result in constipation. The client who is suffering from dehydration may experience urinary tract infections. His urine may look dark and cloudy. Loose and bloody stools are not typically associated with dehydration. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.6: Apply critical thinking in a selected simulated situation related to the care of the older adult.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 28 Question 1 Type: MCMA The nurse is preparing to perform an interview to obtain information about the client. Which of the following are classified as secondary sources of information? Standard Text: Select all that apply. 1. The client’s wife 2. The client’s medical record from his last hospital admission 3. The client 4. The client’s daughter 5. The client’s physical therapist Correct Answer: 1,2,4,5 Rationale 1: The client’s wife: The client’s wife is an example of a secondary source of information. Rationale 2: The client’s medical record from his last hospital admission: The client’s medical record is an example of a secondary source of information. Rationale 3: The client: The client is the primary source of information. Rationale 4: The client’s daughter: The client’s daughter is an example of a secondary source of information. Rationale 5: The client’s physical therapist: The client’s physical therapist is another member of the client’s health team and is a secondary source of information. Global Rationale: The client’s wife is an example of a secondary source of information. The client’s medical record is an example of a secondary source of information. The client’s daughter is an example of a secondary source of information. The client’s physical therapist is another member of the client’s health team and is a secondary source of information. The client is the primary source of information. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.1: Use professional communication skills to gather subjective data in a health history. Question 2

Type: MCMA The nurse is interviewing the client. Which of the following may lead to communication breakdown between the nurse and client? Standard Text: Select all that apply. 1. The client is a Native American and the nurse is of Northern European descent. 2. During the interview, the nurse is trying to remember what the healthcare provider asked her to do earlier in the day. 3. The young nurse creates an informal atmosphere to discuss safe sexual practices with a teenaged client. 4. The young nurse uses a serious and respectful tone to discuss erectile dysfunction with an older client. 5. The nurse states, “So, you experience pain with micturation.” Correct Answer: 1,2,5 Rationale 1: The client is a Native American and the nurse is of Northern European descent. Communication has an increased chance of breaking down when the nurse and the client are from different cultures. Some Native Americans believe that direct eye contact is an invasion of privacy and a firm handshake can be an aggressive action. A person of Northern European descent may feel that a person who avoids direct eye contact is untrustworthy and a weak handshake indicates the client has a weak demeanor. Rationale 2: During the interview, the nurse is trying to remember what the healthcare provider asked her to do earlier in the day. Communication can break down when the nurse fails to decode the messages by not actively listening to the client. Rationale 3: The young nurse creates an informal atmosphere to discuss safe sexual practices with a teenaged client. It is appropriate for the nurse to create an informal atmosphere when discussing a sensitive topic with a younger client. Rationale 4: The young nurse uses a serious and respectful tone to discuss erectile dysfunction with an older client. It is appropriate for the young nurse to use a serious and respectful when discussing a sensitive topic with an older client. Rationale 5: The nurse states, “So, you experience pain with micturation.” Communication can break down easily when nurses use words that clients do not understand. The nurse should avoid medical jargon. Global Rationale: Communication has an increased chance of breaking down when the nurse and the client are from different cultures. Some Native Americans believe that direct eye contact is an invasion of privacy and a firm handshake can be an aggressive action. A person of Northern European descent may feel that a person who avoids direct eye contact is untrustworthy and a weak handshake indicates the client has a weak demeanor. Communication can break down when the nurse fails to decode the messages by not actively listening to the client. Communication can break down easily when nurses use words that clients do not understand. The nurse should avoid medical jargon. It is appropriate for the nurse to create an informal atmosphere when discussing a

sensitive topic with a younger client. It is appropriate for the young nurse to use a serious and respectful when discussing a sensitive topic with an older client. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.1: Use professional communication skills to gather subjective data in a health history. Question 3 Type: FIB The client weighs 224 pounds. How many kilograms does the client weigh? Round to the nearest tenth. kilograms Standard Text: Correct Answer: 101.8 kilograms Rationale: There are 2.2 pounds in 1 kilogram. The client weighs 224 pounds. The nurse can divide the client’s weight in pounds by 2.2 and determine that the client weighs 101.8181 kilograms. When rounded to the nearest tenth, the client weighs 101.8 kilograms. Global Rationale: Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 4 Type: FIB The client weighs 145 kilograms. The client is 1.75 meters. What is this client’s body mass index (BMI) using the following formula: BMI = weight (kg)/height2 (meters)? Round to the nearest whole number. Standard Text: Correct Answer: 47 Rationale: Body mass index (BMI) is widely used to assess appropriate weight for height using the following formula: BMI = weight (kg)/ height2 (meters). 145 divided by 1.752 = 47.3469. When rounded to the nearest whole number, the client’s BMI is 47. Global Rationale:

Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 5 Type: MCSA The nurse is interviewing the client and learns that the client has an open leg wound that has been draining a moderate amount of yellowish drainage over the last 3 days. Prior to assessing the client’s wound, which of the following pieces of personal protective equipment is most important for the nurse to wear based on the principles of standard precautions? 1. Fluid-resistant gown 2. Shoe covers 3. Mask 4. Gloves Correct Answer: 4 Rationale 1: A fluid-resistant gown should be worn if the client’s leg drainage cannot be contained adequately and the drainage has the potential to contaminate the nurse’s clothing. Rationale 2: Shoe covers are important to wear if the client’s drainage cannot be contained adequately and has the potential to contaminate the nurse’s shoes. Along with the shoe covers, the nurse should also wear a fluidresistant gown and gloves if the drainage cannot be contained. Rationale 3: A mask should be worn if the client has a productive cough. Rationale 4: The nurse should always follow standard precautions while assessing the client. The most important personal protective equipment for the nurse to wear is a pair of gloves. Global Rationale: The nurse should always follow standard precautions while assessing the client. The most important personal protective equipment for the nurse to wear is a pair of gloves. A fluid-resistant gown should be worn if the client’s leg drainage cannot be contained adequately and the drainage has the potential to contaminate the nurse’s clothing. Shoe covers are important to wear if the client’s drainage cannot be contained adequately and has the potential to contaminate the nurse’s shoes. Along with the shoe covers, the nurse should also wear a fluidresistant gown and gloves if the drainage cannot be contained. A mask should be worn if the client has a productive cough. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 6 Type: MCMA The nurse is performing a physical assessment of the client. Which of the following pieces of information are examples of objective data? Standard Text: Select all that apply. 1. Apical pulse is 94 beats per minute. 2. Blood pressure in right arm is 118/74. 3. The client has a nonproductive cough. 4. The client reports that his pain is severe and throbbing. 5. Respiratory rate is 18 breaths per minute. Correct Answer: 1,2,3,5 Rationale 1: Apical pulse 94 beats per minute. Objective data can be observed or measured by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the professional nurse. An apical pulse is objective data because it can be auscultated. A blood pressure can be auscultated by any professional nurse. Rationale 2: Blood pressure in right arm 118/74. Objective data can be observed or measured by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the professional nurse. A blood pressure can be auscultated by any professional nurse. Rationale 3: The client has a nonproductive cough. Objective data can be observed or measured by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the professional nurse. A client’s cough can be heard by any professional nurse. Rationale 4: The client reports that his pain is severe and throbbing. The client’s description of his pain is subjective data because the nurse must rely on the client to provide this information. Rationale 5: Respiratory rate 18 breaths per minute. Objective data can be observed or measured by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the professional nurse. The client’s respiratory rate can be measured by any professional nurse. Global Rationale: Objective data can be observed or measured by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the professional nurse. An apical pulse is objective data because it can be auscultated. A blood pressure can be auscultated by any professional nurse. A client’s cough can be heard by any professional nurse. The client’s respiratory rate can be measured by any professional nurse. The client’s description of his pain is subjective data because the nurse must rely on the client to provide this information.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 7 Type: MCSA The student nurse is preparing to assess the client while the more experienced nurse assists. Prior to the physical assessment, the client indicates that he has been experiencing severe left lower quadrant pain. Which of the following statements by the student nurse indicates that the student nurse requires further education prior to performing this part of the assessment? 1. “I’m going to start by percussing and palpating the client’s left lower quadrant first.” 2. “I will start the abdominal assessment by inspecting the client’s abdomen.” 3. “I’m going to auscultate the abdomen prior to percussing the abdomen.” 4. “I need to ask the client about the characteristics of his pain.” Correct Answer: 1 Rationale 1: Beginning the assessment with the nontender areas permits the nurse to establish the borders of the affected area. Examination of the painful area can exacerbate symptoms, increase the pain, and force termination of the assessment process. The nurse should delay this part of the assessment until the last portion of the examination. Rationale 2: The nurse should begin the assessment of the client’s abdomen with inspection of the abdomen. Rationale 3: The nurse should auscultate the client’s abdomen, and then percuss the abdomen. Rationale 4: The nurse should inquire about the characteristics of the client’s pain. Global Rationale: Beginning the assessment with the nontender areas permits the nurse to establish the borders of the affected area. Examination of the painful area can exacerbate symptoms, increase the pain, and force termination of the assessment process. The nurse should begin the assessment of the client’s abdomen with inspection of the abdomen. The nurse should auscultate the client’s abdomen, and then percuss the abdomen. The nurse should inquire about the characteristics of the client’s pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 8 Type: MCMA The nurse is performing a physical assessment on a client in an outpatient clinic. The nurse is inspecting and palpating the client’s face, skin folds, axillae, palms, and soles of the feet. The nurse determines the client is diaphoretic. Which of the following statements by the client are expected? Standard Text: Select all that apply. 1. “Your elevator is out and I had to climb three flights of stairs.” 2. “I’ve been running a fever for the last few days.” 3. “I think I have hypothyroidism.” 4. “I’m in a lot of pain today.” 5. “I heard a rumor at work yesterday that layoffs were inevitable.” Correct Answer: 1,2,4,5 Rationale 1: “Your elevator is out and I had to climb three flights of stairs.” Diaphoresis can occur with exertion, such as climbing stairs. Rationale 2: “I’ve been running a fever for the last few days.” Clients who have a fever may become diaphoretic. Rationale 3: “I think I have hypothyroidism.” It is not typically associated with hypothyroidism. More commonly, it is associated with hyperthyroidism. Rationale 4: “I’m in a lot of pain today.” Clients who are in pain may become diaphoretic. Rationale 5: “I heard a rumor at work yesterday that layoffs were inevitable.” Clients who are experiencing emotional stress may become diaphoretic. Global Rationale: Diaphoresis can occur with exertion, such as climbing stairs. Clients who have a fever may develop diaphoresis. Clients who are in pain may become diaphoretic. Clients who are experiencing emotional stress may become diaphoretic. It is not typically associated with hypothyroidism. More commonly, it is associated with hyperthyroidism. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 9 Type: HOTSPOT The nurse prepares to palpate the client’s preauricular lymph nodes. Identify the location of the preauricular lymph nodes on the following figure by drawing an arrow.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The preauricular lymph nodes are located in the front of the client’s ears. Global Rationale: Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 10 Type: MCSA

The student nurse is preparing to insert the otoscope into the adult client’s ear. Which of the following statements indicates that the student nurse requires further education? 1. “I’m going to use the largest speculum that will fit easily into the ear canal.” 2. “I’m going to prepare to insert the otoscope by pulling the pinna down and back.” 3. “The tympanic membrane should look gray and translucent.” 4. “I will ask the client to perform the valsalva maneuver so that I can see how well the tympanic membrane moves.” Correct Answer: 2 Rationale 1: For the best visualization, use the largest speculum that will fit into the auditory canal. Rationale 2: In infants, the pinna is pulled down and back due to the shorter, straight external ear canal. In the adult client, pull the pinna up, back, and out to straighten the canal. Rationale 3: The membrane should be flat, gray, and translucent with no scars. Rationale 4: The valsalva maneuver lets the nurse assess the mobility of the tympanic membrane. Global Rationale: In infants, the pinna is pulled down and back due to the shorter, straight external ear canal. In the adult client, pull the pinna up, back, and out to straighten the canal. For the best visualization, use the largest speculum that will fit into the auditory canal. The membrane should be flat, gray, and translucent with no scars. The valsalva maneuver lets the nurse assess the mobility of the tympanic membrane. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 11 Type: MCSA The nurse holds the tuning fork by the handle and gently strikes the fork on the palm of his hand. Then, the nurse places the base of the fork on the client’s mastoid process. The nurse requests that the client indicate when the sound can no longer be heard. Which of the following tests is the nurse performing? 1. Weber 2. Whisper 3. Rinne

4. Romberg Correct Answer: 3 Rationale 1: The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. The nurse holds the tuning fork by the handle and strikes the fork on the palm of the hand. The nurse places the base of the vibrating fork against the client’s skull. The midline of the anterior portion of the frontal bone is used. Rationale 2: The whisper test is performed by standing to the side of the client at a distance of 1–2 feet and whispering information to the client. The client then repeats the information back to the nurse. Rationale 3: The Rinne test is used to compare air and bone conduction of sound and is performed in this manner. Rationale 4: The Romberg test is used to assess equilibrium. The client stands with feet together and arms at sides, first with eyes opened and then with eyes closed. The client’s ability to maintain balance for 20 seconds with only mild swaying is documented as a negative Romberg test. Global Rationale: The Rinne test is used to compare air and bone conduction of sound and is performed in this manner. The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. The nurse holds the tuning fork by the handle and strikes the fork on the palm of the hand. The nurse places the base of the vibrating fork against the client’s skull. The midline of the anterior portion of the frontal bone is used. The whisper test is performed by standing to the side of the client at a distance of 1–2 feet and whispering information to the client. The client then repeats the information back to the nurse. The Romberg test is used to assess equilibrium. The client stands with feet together and arms at sides, first with eyes opened and then with eyes closed. The client’s ability to maintain balance for 20 seconds with only mild swaying is documented as a negative Romberg test. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 12 Type: MCSA During the physical assessment of the client, the nurse notes that the client is able to shrug her shoulders bilaterally. The function of which of the following cranial nerves is intact? 1. Cranial nerve I (olfactory) 2. Cranial nerve II (optic) 3. Cranial nerve VII (facial) 4. Cranial nerve XI (spinal accessory)

Correct Answer: 4 Rationale 1: Cranial nerve I (olfactory) is also referred to the olfactory nerve. The client with an intact cranial nerve I will be able to identify familiar odors. Rationale 2: Cranial nerve II (optic) is responsible for the client being able to see. Rationale 3: The client who has a functioning cranial nerve VII (facial) will be able to use her facial muscles symmetrically. Rationale 4: An intact cranial nerve XI (spinal accessory) is responsible for allowing the client to shrug her shoulders. Global Rationale: An intact cranial nerve XI is responsible for allowing the client to shrug her shoulders. Cranial nerve I is also referred to as the olfactory nerve. The client with an intact cranial nerve I will be able to identify familiar odors. Cranial nerve II is responsible for the client being able to see. The client who has a functioning cranial nerve VII will be able to use her facial muscles symmetrically. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 13 Type: MCSA The function of the client’s cranial nerve XII (hypoglossal) is intact. The nurse is able to assess this nerve by asking the client to perform which of the following activities? 1. “Can you stick out your tongue?” 2. “I’m going to ask you to taste something and tell me what you think it is.” 3. “Close your eyes and tell me when you feel me touch your face with this wisp of cotton.” 4. “I’m going to lightly touch the back of your throat with this tongue depressor.” Correct Answer: 1 Rationale 1: An intact cranial nerve XII (hypoglossal) allows the client to stick out the tongue. Rationale 2: An intact cranial nerve VII (facial) allows the client to taste. Rationale 3: An intact cranial nerve V (trigeminal) allows the client to identify sensations on the face.

Rationale 4: Cranial nerve X (vagus) is responsible for producing the gag reflex when the back of the client’s throat is lightly touched. Global Rationale: An intact cranial nerve XII (hypoglossal) allows the client to stick out the tongue. An intact cranial nerve VII (facial) allows the client to taste. An intact cranial nerve V (trigeminal) allows the client to identify sensations on the face. Cranial nerve X (vagus) is responsible for producing the gag reflex when the back of the client’s throat is lightly touched. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 14 Type: HOTSPOT The nurse is performing a physical assessment of the client. Identify the location of the right costovertebral angle on the following figure by drawing an arrow to the site.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The costovertebral angle is formed as the ribs articulate with the vertebra. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 15 Type: HOTSPOT The nurse is auscultating the client’s lungs and is able to auscultate bronchovesicular sounds over the client’s right lung. Identify the area where the nurse is able to auscultate these sounds by drawing an arrow to this area.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : Bronchovesicular sounds may be auscultated at the second and third intercostal spaces at the left and right sternal borders. The nurse will hear bronchovesicular sounds. Global Rationale:

Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 16 Type: MCMA The nurse is assessing the client’s cardiovascular system. The nurse is preparing to assess the client for the presence of a lift or heave. Which of the following directions should the nurse provide for the client? Standard Text: Select all that apply. 1. “I am going to put you into a position where your feet are actually above your head.” 2. “I need you to turn to your left side.” 3. “Can you please turn onto your stomach?” 4. “I need you to sit up straight.” 5. “I am going to elevate your head to a 30-degree angle while you lie on your back.” Correct Answer: 4,5 Rationale 1: “I am going to put you into a position where your feet are actually above your head.” The client should not be placed into Trendelenburg position to assess for heaves or lifts. Rationale 2: “I need you to turn to your left side.” The client does not need to turn to the left side to evaluate the presence of heaves or lifts. Rationale 3: “Can you please turn onto your stomach?” The nurse should not evaluate the client’s chest for the presence of heaves or lifts while the client is in a prone position. Rationale 4: “I need you to sit up straight.” The nurse should inspect the client’s chest for heaves or lifts while the client is sitting upright. Rationale 5: “I am going to elevate your head to a 30 degree angle while you lie on your back.” The nurse should inspect the client’s chest for heaves or lifts while the client is in a semi-fowler position with the head of bed at 30 degrees. Global Rationale: The nurse should inspect the client’s chest for heaves or lifts while the client is sitting upright. The nurse should inspect the client’s chest for heaves or lifts while the client is in a semi-fowler position with the head of bed at 30 degrees. The client should not be placed into Trendelenburg position to assess for heaves or

lifts. The client does not need to turn to the left side to evaluate the presence of heaves or lifts. The nurse should not evaluate the client’s chest for the presence of heaves or lifts while the client is in a prone position. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 17 Type: HOTSPOT The nurse is assessing the client’s cardiovascular system during the physical assessment. Identify the point of maximal impulse/apical impulse on the following figure by drawing an arrow to this site.

Standard Text: Select the correct area on the image.

Correct Answer: Rationale : The point of maximum impulse (PMI) is located at the fifth intercostal space in the left midclavicular line. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 18 Type: MCSA The student nurse is performing a physical assessment for the client. The student nurse has identified a venous hum while auscultating the client’s abdomen. Which of the following statements by the student nurse is most consistent with this type of vascular sound? 1. “The sound is a blowing, pulsing sound.” 2. “The sound is soft and constant. The pitch of the sound is low.” 3. “It is grating, rough sound.” 4. “It is tinkling and has a high pitch. The sound is sort of gurgling and irregular.” Correct Answer: 2 Rationale 1: Vascular sounds include bruits and venous hum. A bruit is pulsatile and blowing. Rationale 2: Vascular sounds include bruits and venous hum. A venous hum is soft, continuous, and low-pitched. Rationale 3: A friction rub refers to a rough, grating sound caused by the rubbing together of organs or an organ rubbing on the peritoneum. Rationale 4: The normal bowel sounds heard upon auscultation of the abdomen are irregular, high-pitched, gurgling sounds. Global Rationale: Vascular sounds include bruits and venous hum. A venous hum is soft, continuous, and lowpitched. A bruit is pulsatile and blowing. A friction rub refers to a rough, grating sound caused by the rubbing together of organs or an organ rubbing on the peritoneum. The normal bowel sounds heard upon auscultation of the abdomen are irregular, high-pitched, gurgling sounds. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 19 Type: MCSA

The student nurse percusses the client’s abdomen. Which of the following statements by the student nurse indicate that tympany is present? 1. “The sound is low-pitched, loud, and hollow-sounding.” 2. “It is a high-pitched, soft sound that doesn’t last very long.” 3. “The sound is very loud and has a low tone. The sound has a long duration.” 4. “It sounds like a drum, loud and high-pitched.” Correct Answer: 4 Rationale 1: Resonance is a low-pitched, hollow sound that is loud. Resonance is often heard when percussing the lungs. Rationale 2: Dullness is a high-pitched sound with a short duration. Dullness can be heard when percussing over solid body organs. Rationale 3: Hyperresonance is an abnormally loud, low-toned sound that has a long duration. It is associated with trapped air. Rationale 4: Tympany is a loud, high-pitched, drumlike tone that can be heard when percussing an organ that is filled with air. When percussing the abdomen, tympany is normally present because the intestines are hollow and filled with air. Global Rationale: Tympany is a loud, high-pitched, drumlike tone that can be heard when percussing an organ that is filled with air. When percussing the abdomen, tympany is normally present because the intestines are hollow and filled with air. Resonance is a low-pitched, hollow sound that is loud. Resonance is often heard when percussing the lungs. Dullness is a high-pitched sound with a short duration. Dullness can be heard when percussing over solid body organs. Hyperresonance is an abnormally loud, low-toned sound that has a long duration. It is associated with trapped air. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 20 Type: MCSA The nurse is assessing the client’s neurologic system. The nurse tests the client’s ability to perform stereognosis. Which of the following activities will accurately test this? 1. The nurse places a vibrating tuning fork over the client’s ankle and asks the client to indicate when the vibration can no longer be felt.

2. The nurse asks the client to close her eyes and writes the number 7 in the client’s palm with the base of the nurse’s pen. The nurse asks the client to identify what was written. 3. The nurse asks the client to close her eyes and places a pen in the client’s hand. The nurse asks the client to name the object in her hand. 4. The nurse asks the client to close her eyes and indicate where the nurse is touching the client. Correct Answer: 3 Rationale 1: Vibratory sense is the test to identify if the client can perceive vibration. The inability to perceive vibration may indicate neuropathy. Rationale 2: Graphesthesia is the ability to perceive writing on the skin. The inability to perceive a number on the skin may indicate cortical disease. Rationale 3: Stereognosis is the ability to identify an object without seeing it. The inability to identify a familiar object could indicate cortical disease. Rationale 4: Topognosis is the ability of the client to identify an area of the body that has been touched. The inability of the client to identify a touched area demonstrates sensory or cortical disease. Global Rationale: Stereognosis is the ability to identify an object without seeing it. The inability to identify a familiar object could indicate cortical disease. Vibratory sense is the test to identify if the client can perceive vibration. The inability to perceive vibration may indicate neuropathy. Graphesthesia is the ability to perceive writing on the skin. The inability to perceive a number on the skin may indicate cortical disease. Topognosis is the ability of the client to identify an area of the body that has been touched. The inability of the client to identify a touched area demonstrates sensory or cortical disease. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 21 Type: MCSA The nurse has palpated an abnormal mass within the client’s scrotum. Which of the following assessment activities is appropriate for the nurse to perform next? 1. The nurse should percuss the client’s scrotum. 2. The nurse should attempt to transilluminate behind the area in which the abnormal mass was palpated. 3. The nurse should inspect the inguinal area.

4. The nurse should gently squeeze the mass between the fingers. Correct Answer: 2 Rationale 1: The nurse should not attempt to percuss the client’s scrotum due to an increased number of nerve endings located in this area. Percussing would cause the client unnecessary pain. Rationale 2: If the nurse detects a mass within the client’s scrotum, the nurse should attempt to transilluminate the area. Light will not penetrate a mass. Masses may indicate testicular tumor or a spermatocele. Rationale 3: The nurse should inspect the inguinal area after attempting to transilluminate the client’s scrotal mass. Rationale 4: The nurse should never squeeze or pinch any mass that has been identified. Global Rationale: If the nurse detects a mass within the client’s scrotum, the nurse should attempt to transilluminate the area. Light will not penetrate a mass. Masses may indicate testicular tumor or a spermatocele. The nurse should not attempt to percuss the client’s scrotum due to an increased number of nerve endings located in this area. Percussing would cause the client unnecessary pain. The nurse should inspect the inguinal area after attempting to transilluminate the client’s scrotal mass. The nurse should never squeeze or pinch any mass that the nurse has identified. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 22 Type: MCSA The nurse is performing a physical assessment of a male client. The nurse must assess the client’s sacrococcygeal area. Which of the following positions will allow the nurse to assess this area adequately? 1. Orthopneic position 2. Semi-Fowler’s position 3. Lithotomy 4. On his left side with his knees drawn up Correct Answer: 4 Rationale 1: Orthopneic position is utilized by clients who are unable to breathe with the head of bed lower. Orthopneic position allows the client to sit up straight and use a tripod position to lean over a bedside table.

Rationale 2: The semi-Fowler’s position is when the client is positioned on his back in a dorsal recumbent position. Rationale 3: The nurse can use a lithotomy position to perform a pelvic examination on a female client. Rationale 4: The nurse can visualize the sacrococcygeal area by asking the client to bend over a table at the waist or to lie on the left side with the knees flexed. Global Rationale: The nurse can visualize the sacrococcygeal area by asking the client to bend over a table at the waist or to lie on the left side with the knees flexed. Orthopneic position is utilized by clients who are unable to breathe with the head of bed lower. Orthopneic position allows the client to sit up straight and use a tripod position to lean over a bedside table. The semi-Fowler’s position is when the client is positioned on his back in a dorsal recumbent position. The nurse can use a lithotomy position to perform a pelvic examination. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 23 Type: MCSA The nurse is performing an assessment of the female client’s genitalia. The nurse has inserted a speculum and notices that the client has a frothy greenish-yellowish discharge present within the client’s vagina. Based on the nurse’s findings, the nurse believes that the client has developed which of the following conditions? 1. Trichomoniasis 2. Gonorrhea 3. Chlamydia 4. Candidiasis Correct Answer: 1 Rationale 1: Frothy, yellow-green discharge is seen in a client with trichomoniasis. Rationale 2: Green discharge that has a foul smell is associated with gonorrhea. Rationale 3: A yellow discharge can be visualized in a client with a chlamydial infection. Rationale 4: Thick whitish discharge can be visualized in a client with candidiasis.

Global Rationale: Frothy, yellow-green discharge is seen in a client with trichomoniasis. Green discharge that has a foul smell is associated with gonorrhea. A yellow discharge can be visualized in a client with a chlamydial infection. Thick, whitish discharge can be visualized in a client with candidiasis. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client. Question 24 Type: SEQ The nurse is documenting information about the client using Problem-Oriented Charting and the acronym SOAP. Rank the following pieces of information in the order that they should be documented. Standard Text: Click and drag the options below to move them up or down. Choice 1. The client’s skin is cool and dusky. Poor capillary refill noted. Oxygen saturation level is 90% on room air. The client was diagnosed with COPD in 1993. Choice 2. The nurse will apply oxygen at 2 liters per minute, per healthcare provider’s orders when the client’s oxygen saturation level is below 92%. Choice 3. The client states, “I am so tired all of the time. I feel like I’m not getting enough air into my lungs.” Choice 4. The client is most likely experiencing an exacerbation of a chronic lung disease. Correct Answer: 3,1,4,2 Rationale 1: “S” refers to subjective data that are provided by the client regarding the symptoms that the client is experiencing. Rationale 2: “O” refers to objective data. The nurse documents information about the signs that the client is exhibiting. Rationale 3: “A” refers to assessment. The nurse draws conclusions regarding the subjective and objective data that the nurse has collected about the client. Rationale 4: “P” refers to planning. Planning indicates that interventions that the nurse can use to help resolve the client’s problems or address the client’s needs. Global Rationale: “S” refers to subjective data that are provided by the client regarding the symptoms that the client is experiencing. “O” refers to objective data. The nurse documents information about the signs that the client is exhibiting. “A” refers to assessment. The nurse draws conclusions regarding the subjective and objective data that the nurse has collected about the client. “P” refers to planning. Planning indicates that interventions that the nurse can use to help resolve the client’s problems or address the client’s needs.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.3: Document findings from the comprehensive health assessment.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e Chapter 29 Question 1 Type: SEQ The nurse uses the nursing process to create a plan of care for a hospitalized client. Rank the following activities of the nursing process in the proper order. Standard Text: Click and drag the options below to move them up or down. Choice 1. The nurse educates the client regarding the care of his sternal and leg incisions. Choice 2. The client is admitted to the hospital with chest pain. The client is admitted with an evolving myocardial infarction and is taken to surgery for a coronary artery bypass graft. Choice 3. The nurse determines that the client has an impaired skin integrity and an increased risk for the development of an infection. Choice 4. The nurse develops a plan to help prevent some of the known complications associated with surgery. Correct Answer: 2,3,1,4 Rationale 1: The steps of the nursing process begin with the assessment phase. The nurse assesses the objective and subjective information about the client. Rationale 2: The second step is to create a nursing diagnosis using NANDA nursing labels. Rationale 3: The third step is to develop a plan to help the client heal and prevent the development of complications. Rationale 4: The fourth step is to implement nursing interventions that are based on the developed plan. The last step is to evaluate how well the nurse’s plan for the client worked. Global Rationale: The steps of the nursing process begin with the assessment phase. The nurse assesses the objective and subjective information about the client. The second step is to create a nursing diagnosis using NANDA nursing labels. The third step is to develop a plan to help the client heal and prevent the development of complications. The fourth step is to implement nursing interventions that are based on the developed plan. The last step is to evaluate how well the nurse’s plan for the client worked. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.1: Discuss the types of assessment carried out with the hospitalized client. Question 2

Type: MCMA The nurse works on a medical-surgical unit. Which of the following clients will require a rapid assessment? Standard Text: Select all that apply. 1. The client had an open appendectomy 2 days ago and is preparing to be discharged today. 2. The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia. 3. The client has just been received from the Post Anesthesia Care Unit. 4. The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse. 5. The client begins to complain of difficulty breathing. The client’s oxygen saturation level has decreased from 93% on room air this morning to 87%. Correct Answer: 3,4,5 Rationale 1: The client had an open appendectomy 2 days ago and is preparing to be discharged today. The client who is postoperative day 2 and is preparing to be discharged requires a routine assessment. Rationale 2: The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia. The client who has been admitted to the unit the day before and is receiving effective treatment requires a routine assessment. Rationale 3: The client has just been received from the Post Anesthesia Care Unit. The nurse should perform a rapid assessment on a client following a surgical procedure. Rationale 4: The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse. The nurse who is new to the unit can plan care for the assigned clients by performing a rapid assessment on each of the assigned clients to help the nurse prioritize care. Rationale 5: The client begins to complain of difficulty breathing. The client’s oxygen saturation level has decreased from 93% on room air this morning to 87%. The nurse should perform a rapid assessment on a client who is in distress. Global Rationale: The nurse should perform a rapid assessment on a client following a surgical procedure. The nurse who is new to the unit can plan care for the assigned clients by performing a rapid assessment on each of the assigned clients to help the nurse prioritize care. The nurse should perform a rapid assessment on a client who is in distress. The client who is postoperative day 2 and is preparing to be discharged requires a routine assessment. The client who has been admitted to the unit the day before requires a routine assessment. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.1: Discuss the types of assessment carried out with the hospitalized client.

Question 3 Type: MCSA The student nurse is preparing to perform a rapid assessment as the more experienced nurse observes. Which of the following statements by the student nurse indicate that further education is required? 1. “The rapid assessment should last approximately 10 minutes.” 2. “I should perform a rapid assessment for all of my assigned clients at the beginning of the shift to help me prioritize care.” 3. “The rapid assessment will help me establish baseline data about the client.” 4. “After I perform the rapid assessments on the clients I’ve been assigned, I can go back and get more information during my routine assessments.” Correct Answer: 1 Rationale 1: The nurse should be able to perform the rapid assessment within 1 minute, not 10 minutes. Rationale 2: It will be helpful for the nurse to help plan care for the clients that have been assigned to the new nurse by performing rapid assessments at the beginning of the shift on all of the assigned clients. Rationale 3: The rapid assessment helps the nurse establish baseline data about the client. Rationale 4: Following the rapid assessment, the nurse can go back later and perform a routine assessment to gather more information about the client. Global Rationale: The nurse should be able to perform the rapid assessment within 1 minute, not 10 minutes. It will be helpful for the nurse to help plan care for the clients that have been assigned to the new nurse by performing rapid assessments at the beginning of the shift on all of the assigned clients. The rapid assessment helps the nurse establish baseline data about the client. Following the rapid assessment, the nurse can go back later and perform a routine assessment to gather more information about the client. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.1: Discuss the types of assessment carried out with the hospitalized client. Question 4 Type: MCMA 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? Standard Text: Select all that apply.

1. “It seems like I get catch every bug that comes along. I can’t seem to stay well.” 2. “This wound that I’ve had for the last 3 months on my leg won’t heal.” 3. “I have gained 5 pounds over the last week and my ankles and feet are swollen.” 4. “My nails are so brittle.” 5. “I know my blood pressure has been up because I’ve been experiencing headaches in the morning, just like last time.” Correct Answer: 1,2,4 Rationale 1: “It seems like I get catch every bug that comes along. I can’t seem to stay well.” Undernutrition can lead to a compromised immune status. Rationale 2: “This wound that I’ve had for the last 3 months on my leg won’t heal.” Undernutrition can lead to poor wound healing. Rationale 3: “I have gained 5 pounds over the last week and my ankles and feet are swollen.” Edema in the feet and ankles along with weight gain is often associated with a poor cardiovascular status or renal insufficiency. These types of signs are not typically associated with undernutrition. Rationale 4: “My nails are so brittle.” Undernutrition can lead to the development of brittle nails and hair. Rationale 5: “I know my blood pressure has been up because I’ve been experiencing headaches in the morning, just like last time.” The client with hypertension can experience headaches in the morning. Hypertension is not typically associated with undernutrition. Global Rationale: Undernutrition can lead to a compromised immune status. Undernutrition can lead to poor wound healing. Undernutrition can lead to the development of brittle nails and hair. Edema in the feet and ankles along with weight gain is often associated with a poor cardiovascular status or renal insufficiency. These types of signs are not typically associated with undernutrition. The client with hypertension can experience headaches in the morning. Hypertension is not typically associated with undernutrition. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 29.2: Conduct a rapid and routine assessment of a hospitalized client. Question 5 Type: MCSA 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. “Emotional stress can negatively impact his immune system’s ability to function.” 2. “He’s probably not been eating well recently.” 3. “I should not ask about his use of drugs or alcohol at this time.” 4. “He may be hyperglycemic.” Correct Answer: 3 Rationale 1: Emotional stress affects the immune system resulting in increased susceptibility to infection. Rationale 2: During periods of stress or change, individuals are less likely to attend to habits that promote health such as eating nutritious meals. Rationale 3: Some individuals use alcohol, tobacco, or drugs to “feel better.” The nurse must assess the client’s use of drugs or alcohol at this time. Rationale 4: The client who is experiencing emotional stress is more likely to develop an increased serum glucose level due to the increased level of circulating stress hormones. Global Rationale: Some individuals use alcohol, tobacco, or drugs to “feel better.” The nurse must assess the client’s use of drugs or alcohol at this time. Emotional stress affects the immune system resulting in increased susceptibility to infection. During periods of stress or change, individuals are less likely to attend to habits that promote health such as eating nutritious meals or following an exercise routine. The client who is experiencing emotional stress is more likely to develop an increased serum glucose level due to the increased level of circulating stress hormones. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.2: Conduct a rapid and routine assessment of a hospitalized client Question 6 Type: SEQ 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. Standard Text: Click and drag the options below to move them up or down. Choice 1. The nurse percusses the client’s thorax. Choice 2. The nurse unties the client’s gown to better visualize the client’s thorax. Choice 3. The nurse warms his stethoscope and listens to the client’s lung sounds in each lung field.

Choice 4. The nurse gently palpates the client’s thorax. Correct Answer: 3,1,4,2 Rationale 1: The first thing that the nurse should do is to perform a visual inspection of the client’s thorax. Rationale 2: The second step is for the nurse to gently palpate the client’s thorax. Rationale 3: The third step is for the nurse to percuss the client’s thorax. Rationale 4: The last step is for the nurse to auscultate the client’s lungs. Global Rationale: When performing a physical assessment, the nurse utilizes four basic techniques to obtain objective and measurable data. These techniques are inspection, palpation, percussion, and auscultation and are performed in an organized manner. This pattern of organization varies when assessing the abdomen. The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 7 Type: MCMA The nurse is performing a rapid assessment for each of the following clients. Which of the following clients require immediate medical assistance? Standard Text: Select all that apply. 1. The client is pale and is breathing in a shallow manner. 2. The client’s oxygen saturation level is 74% and is dyspneic. 3. The client is rating his pain at a 3 out of a 10 on a pain scale. 4. The client is unable to follow directions. 5. The nurse determines that the client’s level of consciousness is decreasing. Correct Answer: 1,2,4,5 Rationale 1: The client is pale and is breathing in a shallow manner. The client who is pale and breathing in a shallow manner may be exhibiting anxiety. This client should receive immediate medical attention.

Rationale 2: The client’s oxygen saturation level is 74% and is dyspneic. The client who has an oxygen saturation level of 74% and is dyspneic is exhibiting clinical manifestations associated with cardiovascular problems. This client should receive immediate medical attention. Rationale 3: The client is rating his pain at a 3 out of a 10 on a pain scale. The client who is complaining of only mild pain does not require immediate medical assistance. Rationale 4: The client is unable to follow directions. The client who is unable to follow directions should be provided with immediate medical attention. Rationale 5: The nurse determines that the client’s level of consciousness is decreasing. The client who has a decreasing level of consciousness during the rapid assessment should be provided with immediate medical assistance. The rapid assessment lasts less than 1 minute. This client’s level of consciousness is decreasing very quickly and indicates a severe problem is occurring. Global Rationale: The client who is pale and breathing in a shallow manner may be exhibiting anxiety. This client should receive immediate medical attention. The client who has an oxygen saturation level of 74% and is dyspneic is exhibiting clinical manifestations associated with cardiovascular problems. This client should receive immediate medical attention. The client who is unable to follow directions should be provided with immediate medical attention. The client who has a decreasing level of consciousness during the rapid assessment should be provided with immediate medical assistance. The rapid assessment lasts less than 1 minute. This client’s level of consciousness is decreasing very quickly and indicates a severe problem is occurring. The client who is complaining of only mild pain does not require immediate medical assistance. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 8 Type: MCMA The client 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? Standard Text: Select all that apply. 1. “When I was little I had 4 cats. Can I wear a dress instead of this hospital gown?” 2. “I wish that my grandmother’s daughter would visit me more often.” 3. “I have never had so much pain. I just don’t feel like speaking with you right now.” 4. “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.”

5. “Red squirrels dance on the divine divide.” Correct Answer: 1,2,5 Rationale 1: “When I was little I had 4 cats. Can I wear a dress instead of this hospital gown?” The client who frequently jumps from one subject to another is exhibiting a flight of ideas. Flight of ideas is associated with altered thought processes. Rationale 2: “I wish that my grandmother’s daughter would visit me more often.” The client who is unable to communicate ideas easily is exhibiting circumlocution. It would’ve been easier for the client to state that he or she wished her mother would visit more frequently. Rationale 3: “I have never had so much pain. I just don’t feel like speaking with you right now.” The client who is experiencing pain may not feel like communicating with the nurse. This is not an example of altered thought processes. Rationale 4: “My doctor has only been to visit me once during the last 3 days. I’m starting to feel angry that she hasn’t come to see if I’m doing better.” It would be appropriate for the client to feel that the healthcare provider should visit the client more often than once in three days. This statement does not indicate that the client is experiencing altered thought processes. Rationale 5: “Red squirrels dance on the divine divide.” The client who is unable to communicate an idea that makes sense in the context of the situation is exhibiting word salad. Global Rationale: The client who frequently jumps from one subject to another is exhibiting a flight of ideas. Flight of ideas is associated with altered thought processes. The client who is unable to communicate ideas easily is exhibiting circumlocution. It would’ve been easier for the client to state that she wished her mother would visit more frequently. The client who is unable to communicate an idea that makes sense in the context of the situation is exhibiting word salad. The client who is experiencing pain may not feel like communicating with the nurse. This is not an example of altered thought processes. It would be appropriate for the client to feel that the healthcare provider should visit the client more often than once in 3 days. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 9 Type: MCMA The nurse is performing routine assessments on five hospitalized clients. Which of the following clients does the nurse expect to exhibit poor skin turgor? Standard Text: Select all that apply. 1. The client had an open appendectomy 2 days ago.

2. The client was admitted with severe nausea and vomiting. 3. The client has lost 16 pounds during the last 30 days. 4. The client has had a high fever during the last four days and was admitted through the Emergency Department last night. 5. The client was admitted this morning with a severe migraine. Correct Answer: 2,3,4 Rationale 1: The client had an open appendectomy 2 days ago. The client who had an open appendectomy will most likely be prepared for discharge at this time. It is unlikely that this client will exhibit poor skin turgor at this time. Rationale 2: The client was admitted with severe nausea and vomiting. The client who was admitted with severe nausea and vomiting will most likely exhibit signs associated with dehydration. Poor skin turgor is associated with dehydration. Rationale 3: The client has lost 16 pounds during the last 30 days. The client who has lost a large amount of weight will often exhibit poor skin turgor. Rationale 4: The client has had a high fever during the last four days and was admitted through the Emergency Department last night. The client who has had a high fever will often exhibit poor skin turgor due to dehydration. Rationale 5: The client was admitted this morning with a severe migraine. The client who has a severe migraine will not necessarily demonstrate signs of dehydration. Global Rationale: The client who was admitted with severe nausea and vomiting will most likely exhibit signs associated with dehydration. Poor skin turgor is associated with dehydration. The client who has lost a large amount of weight will often exhibit poor skin turgor. The client who has had a high fever will often exhibit poor skin turgor due to dehydration. The client who had an open appendectomy will most likely be prepared for discharge at this time. It is unlikely that this client will exhibit poor skin turgor at this time. The client who has a severe migraine will not necessarily demonstrate signs of dehydration. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 10 Type: MCSA 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. “I will need to turn the client into the prone position.” 2. “The probe for a rectal thermometer is usually red.” 3. “I should insert the thermometer 1.5 to 4 centimeters into the client’s anus.” 4. “This is an appropriate way to monitor a client’s temperature if they are unable to close the mouth around the oral thermometer.” Correct Answer: 1 Rationale 1: The client should be turned to the side, not the prone position. Rationale 2: The rectal thermometer probe is usually red to signify that it is different from an oral thermometer probe. Rationale 3: The thermometer should be placed 1.5 to 4 centimeters into the client’s anus. Rationale 4: This route may be used if the client is unable to close his or her mouth around an oral thermometer probe. Global Rationale: The client should be turned to the side, not the prone position. The rectal thermometer probe is usually red to signify that it is different from an oral thermometer probe. The thermometer should be placed 1.5 to 4 centimeters into the client’s anus. This route may be used if the client is unable to close his or her mouth around an oral thermometer probe. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 11 Type: MCMA The nurse is performing a routine assessment on a dark-skinned client who has been admitted to the hospital. The nurse is assessing the client’s oxygenation level and the presence of jaundice. Which of the following statements by the nurse to the client indicate that the nurse is performing these specific assessments? Standard Text: Select all that apply. 1. “I need to look at your eyes.” 2. “Please open your mouth for me.” 3. “Squeeze my fingers with your hands.” 4. “I am going to listen to your belly with my stethoscope.”

5. “I need to press on your fingernail.” Correct Answer: 1,2,5 Rationale 1: “I need to look at your eyes.” The nurse should look into the dark-skinned client’s eyes to examine the sclera for the presence of jaundice. The nurse can also examine the client’s conjunctiva to assess for the presence of pallor and oxygenation status. Rationale 2: “Please open your mouth for me.” The nurse should examine the inside of the client’s mouth to assess the mucous membranes for the client’s oxygenation status. Rationale 3: “Squeeze my fingers with your hands.” The nurse should assess the client’s neurological status by asking the client to squeeze both of the nurse’s hands bilaterally. Rationale 4: “I am going to listen to your belly with my stethoscope.” The nurse should assess the client’s bowel sounds during the gastrointestinal system assessment. Rationale 5: “I need to press on your fingernail.” The nurse can assess the client’s capillary refill by pressing on the client’s fingernails to determine the client’s level of oxygenation. Global Rationale: The nurse should look into the dark-skinned client’s eyes to examine the sclera for the presence of jaundice. The nurse can also examine the client’s conjunctiva to assess for the presence of pallor and oxygenation status. The nurse should examine the inside of the client’s mouth to assess the mucous membranes for the client’s oxygenation status. The nurse can assess the client’s capillary refill by pressing on the client’s fingernails to determine the client’s level of oxygenation. The nurse should assess the client’s neurological status by asking the client to squeeze both of the nurse’s hands bilaterally. The nurse should assess the client’s bowel sounds during the gastrointestinal system assessment. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 12 Type: MCMA During the physical assessment of a hospitalized client, the client stated, “I’ve been under an incredible amount of stress after the healthcare provider diagnosed me with colon cancer 2 days ago.” Which of the following findings are associated with increased stress? Standard Text: Select all that apply. 1. Apical heart rate is 104 beats per minute. 2. Respiratory rate is 16 breaths per minute. 3. Pupils were equal, dilated, and round.

4. Client is hypoglycemic. 5. Blood pressure is 158/94. Correct Answer: 1,3,5 Rationale 1: Apical heart rate 104 beats per minute. When the client is experiencing increased levels of stress, the apical heart rate increases. Rationale 2: Respiratory rate 16 breaths per minute. The client with increased levels of stress will have an increased respiratory rate. This is a normal value. Rationale 3: Pupils were equal, dilated, and round. The client who is experiencing increased levels of stress may exhibit dilated pupils. Rationale 4: Client is hypoglycemic. The client with increased levels of stress will have an increased serum glucose level. This is a normal value. Rationale 5: Blood pressure 158/94. The client who is experiencing increased levels of stress may have an increased blood pressure. Global Rationale: When the client is experiencing increased levels of stress, the apical heart rate increases. The client who is experiencing increased levels of stress may exhibit dilated pupils. The client who is experiencing increased levels of stress may have an increased blood pressure. The client with increased levels of stress will have an increased respiratory rate. The client with increased levels of stress will have an increased serum glucose level. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 13 Type: MCSA The student nurse has measured the client’s oxygen saturation level by using a pulse oximeter. The student nurse confers with the experienced nurse. Which of the following statements indicate the student nurse requires further education? 1. “A normal finding is that the client’s oxygen saturation level is above 70%.” 2. “The pulse oximeter can measure the oxygen saturation of the hemoglobin.” 3. “I placed the sensor on the client’s finger.” 4. “This test is noninvasive and painless.”

Correct Answer: 1 Rationale 1: A normal finding is that the client’s oxygen saturation is above 95%, not above 70%. A client with an oxygen saturation of only 70% has an increased risk of dying due to complications of poor oxygenation. Rationale 2: The pulse oximeter measures the oxygen saturation of the client’s hemoglobin. The reported percentage represents the light absorbed by oxygenated and deoxygenated hemoglobin. Rationale 3: The sensor may be placed on the client’s finger or earlobe. Rationale 4: The test is noninvasive and will not cause the client to feel pain. Global Rationale: A normal finding is that the client’s oxygen saturation is above 95%, not above 70%. A client with an oxygen saturation of only 70% has an increased risk of dying due to complications of poor oxygenation. The pulse oximeter measures the oxygen saturation of the client’s hemoglobin. The reported percentage represents the light absorbed by oxygenated and deoxygenated hemoglobin. The sensor may be placed on the client’s finger or earlobe. The test is noninvasive and will not cause the client to feel pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 14 Type: MCMA The nurse is preparing to place the pulse oximeter sensor on the client. The nurse places the pulse oximeter sensor on the earlobes of which of the following clients? Standard Text: Select all that apply. 1. The client’s body mass index is 33. 2. The client has been diagnosed with an evolving myocardial infarction. 3. The client is wearing dark nail polish. 4. The client is 82 years old. 5. The client has thickened nails. Correct Answer: 1,2,3,5 Rationale 1: The client’s body mass index is 33. The client who has a body mass index of 33 is considered to be obese. The nurse should place the pulse oximeter sensor on this client’s earlobe.

Rationale 2: The client has been diagnosed with an evolving myocardial infarction. The nurse should place the pulse oximeter sensor on the earlobe of a client with a vascular disease. Rationale 3: The client is wearing dark nail polish. The nurse will not be able to get an accurate reading of the client’s oxygen saturation level if the client is wearing dark nail polish. The nurse should place the pulse oximeter sensor on the earlobe of this client. Rationale 4: The client is 82-years-old. The nurse does not necessarily need to place the pulse oximeter sensor on the client who is older. Rationale 5: The client has thickened nails. The nurse will not be able to get an accurate reading of the client’s oxygen saturation level if the client has thickened nails. The nurse should place the pulse oximeter sensor on the earlobe of this client. Global Rationale: The client who has a body mass index of 33 is considered to be obese. The nurse should place the pulse oximeter sensor on this client’s earlobe because this is the best way to gain information about an obese client’s oxygen saturation level. The nurse should place the pulse oximeter sensor on the earlobe of a client with a vascular disease. The nurse will not be able to get an accurate reading of the client’s oxygen saturation level if the client is wearing dark nail polish. The nurse should place the pulse oximeter sensor on the earlobe of this client. The nurse will not be able to get an accurate reading of the client’s oxygen saturation level if the client has thickened nails. The nurse should place the pulse oximeter sensor on the earlobe of this client. The nurse does not necessarily need to place the pulse oximeter sensor on the client who is older. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 15 Type: MCSA The student nurse is preparing to auscultate the client’s lungs during the initial assessment. The student nurse is being assisted by the experienced nurse. Which of the following statements by the student nurse indicate the need for further education? 1. “I should think about how loud the auscultated sound is, the tone of the sound, and how long it lasts.” 2. “I should leave the client’s television on during the assessment to make the client feel relaxed and comfortable during the assessment.” 3. “I have to remember to keep the client warm during this part of the assessment.” 4. “I cannot listen through the client’s gown.” Correct Answer: 2

Rationale 1: The student nurse should note the intensity, pitch, and duration of the auscultated sound. Auscultating body sounds requires a quiet environment in which the nurse can listen not just for the presence or absence of sounds, but also for the characteristics of each sound. Rationale 2: External distractions such as radios, televisions, and loud equipment should be eliminated whenever possible. Rationale 3: The student nurse should ensure that the client remains warm during this part of the assessment because shivering can impair the nurse’s ability to hear the sound well. The nurse cannot listen through gowns or drapes. Rationale 4: The student nurse should place the stethoscope firmly over the area to be auscultated. Global Rationale: Auscultating body sounds requires a quiet environment in which the nurse can listen not just for the presence or absence of sounds, but also for the characteristics of each sound. External distractions such as radios, televisions, and loud equipment should be eliminated whenever possible. The student nurse should note the intensity, pitch, and duration of the auscultated sound. The student nurse should ensure that the client remains warm during this part of the assessment because shivering can impair the nurse’s ability to hear the sound well. The nurse cannot listen through gowns or drapes. The student nurse should place the stethoscope firmly over the area to be auscultated. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 16 Type: FIB The hospitalized client has an indwelling urinary catheter. The client has had 230 milliliters of urine collect in the drainage bag over the last 8 hours. How many milliliters of urine is the client producing on average each hour? Round to the nearest whole number. milliliters per hour Standard Text: Correct Answer: 29 milliliters per hour Rationale: The client has produced 230 milliliters of urine over the last 8 hours. 230 divided by 8 is 28.75. When rounded to the nearest whole number, it is 29 milliliters per hour. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client Question 17 Type: FIB The hospitalized client’s healthcare provider writes an order for the client to receive 1000 milliliters of normal saline over 7 hours. How many milliliters per hour should the nurse set the IV pump for? Round the answer to the nearest whole number. milliliters per hour Standard Text: Correct Answer: 143 milliliters per hour Rationale: 1000 milliliters divided by 7 hours is 142.85714 milliliters per hour. When rounded to the nearest whole number, the answer is 143 milliliters per hour. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client. Question 18 Type: SEQ The nurse has assessed the hospitalized client. The nurse is preparing to document the findings using APIE. Rank the following findings in the proper order of documentation. Standard Text: Click and drag the options below to move them up or down. Choice 1. The client states upon admission, “I don’t know what’s wrong with me, but I can’t see out of my left eye and I can’t stand up by myself.” Choice 2. The client is unable to move from the bed to the chair without the assistance of two nurses. The client is unable to eat without assistance. Choice 3. The healthcare provider writes an order for the nurse to administer heparin. Choice 4. On the morning of the client’s discharge from the hospital, the client has been able to ambulate 50 feet with a walker. Correct Answer: 2,3,4,1 Rationale 1: The letters APIE refer to Assessment, Problem, Intervention, and Evaluation. When using this method, documentation of assessment includes combining the subjective and objective data.

Rationale 2: The letters APIE refer to Assessment, Problem, Intervention, and Evaluation. The nurse will draw conclusions from the data, identify and record the problem or problems, and plan to address these problems. Rationale 3: The letters APIE refer to Assessment, Problem, Intervention, and Evaluation. Interventions are documented as they are carried out. Rationale 4: The letters APIE refer to Assessment, Problem, Intervention, and Evaluation. Evaluation refers to documentation of the response to the plan. Global Rationale: The letters APIE refer to Assessment, Problem, Intervention, and Evaluation. When using this method, documentation of assessment includes combining the subjective and objective data. The nurse will draw conclusions from the data, identify and record the problem or problems, and plan to address these problems. Interventions are documented as they are carried out. Evaluation refers to documentation of the response to the plan. Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.4: Document findings from assessment of the hospitalized client.