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Test Bank For Health Assessment in Nursing, 6th Edition

  • Nursing
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    Page 1 1. Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. Which of the following nursing diagnoses would be the nurse's priority? A) Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination B) Imbalanced nutrition: more than body requirements related to diabetes C) Potential complication: hypertension D) Powerlessness related to diabetes self-care and management 2. The nurse's assessment reveals that a client is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate? A) Teaching the client muscle-building exercises B) Discussing ways to increase body fat stores C) Assisting client in reducing the amount of fluid build-up D) Encouraging the use of a multivitamin supplement 3. An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following? A) 12 B) 18 C) 25 D) 28 4. A client weighs 106 pounds and is 5 feet 5 inches tall. As a result, her ideal body weight is 120 pounds. After determining the client's percentage of ideal body weight, which of the following should the nurse conclude? A) Client is mildly malnourished. B) Client is experiencing moderate malnutrition. C) Severe malnutrition is present. D) The client's body weight is within 10% of ideal body weight. 5. A nurse is reviewing the laboratory test results of an adult client who has numerous chronic health challenges. Which assessment result would alert the nurse to potential malnutrition? A) Hemoglobin of 13.1 g/dL B) Hematocrit of 40% C) Serum albumin of 2.6 g/dL D) Total protein of 7 g/dL

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    Page 2 6. The nurse should prioritize assessments related to overhydration for a client experiencing which of the following health problems? A) Early congestive heart failure B) Chronic emphysema C) Newly diagnosed hepatitis C virus infection D) Adult respiratory distress syndrome 7. The nurse is assessing a client who has been admitted with signs and symptoms that are consistent with malnutrition. Which of the following physiological phenomena would the nurse recognize as an early indicator of malnutrition? A) Protein stores are lower than normal B) Bone is metabolized to compensate for missing nutrients C) Calcium levels decrease D) Hemoglobin levels decrease 8. A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. Which of the following conclusions is suggested if the client has no reaction? A) It indicates high cholesterol and triglyceride levels. B) It shows a sacrifice of skeletal muscle proteins and blood proteins. C) It is indicative of unhealthy dietary habits. D) It may be immunosuppression resulting from undernourishment. 9. The nurse is preparing to perform a nutritional assessment of a newly admitted client. Which of the following questions would be most appropriate to use when initiating the assessment? A) ìDid you eat breakfast today?î B) ìHow many meals do you eat each day?î C) ìCan you tell me what you've eaten in the last 24 hours?î D) ìHow often do you eat out?î 10. A nurse is assessing a client's skeletal muscle mass in the context of a comprehensive nutritional assessment. Which measurement would yield the most valid and reliable data? A) Body mass index B) Triceps skin fold measurement C) Mid-arm circumference D) Waist circumference

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    Page 3 11. When evaluating nutrition in an adult female client, which laboratory value would most concern the nurse? A) Hemoglobin A1c of 9% B) Serum albumin of 4.9 g/dL C) Total protein of 6.7 g/dL D) Hematocrit of 39% 12. A nurse weighs a client today and finds that the client's weight has increased 2.2 lbs from the previous day. The nurse interprets this finding as suggesting a fluid gain of which amount? A) 0.5 liters B) 1.0 liters C) 1.5 liters D) 2.0 liters 13. The nurse analyzes the data obtained from a client's nutritional assessment and develops a health promotion diagnosis related to nutrition for a client. Which of the following would be the best example? A) Health-seeking behaviors related to desire and request to alter amount of food intake B) Imbalanced nutrition: less than body requirements related to inadequate caloric intake C) Imbalanced nutrition: more than body requirements related to excessive caloric intake D) Ineffective thermoregulation related to decreased adaptability to cold secondary to decreased subcutaneous tissue 14. The nurse is collecting data from a client about his nutrition. Which of the following would the nurse document as objective data? A) Client states he is not eating well. B) Client complains of nausea and vomiting. C) Clients experiences urinary frequency. D) Tenting of client's skin observed upon skin pinch. 15. A nurse in the intensive care unit is calculating an acutely ill client's 24-hour fluid balance. The nurse should include insensible fluid losses of what volume when performing this assessment? A) 100 to 300 mL B) 450 to 650 mL C) 800 to 1000 mL D) 1200 to 1400 mL

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    Page 4 16. A nurse is assessing a client for possible fluid overload. Which of the following assessment findings is most consistent with this diagnosis? A) Venous filling of 3 seconds B) Distended neck veins with head elevated at 45 degrees C) Moist, plump tongue D) Boggy eyeball 17. During a nutritional assessment, the client asks the nurse for suggestions to improve her diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to desire to improve diet. Which of the following suggestions would be most appropriate? A) ìThe majority of your diet should consist of whole grains.î B) ìChoose low-fat versions of milk products such as yogurt.î C) ìDrink at least 2 to 3 glasses of fruit juices a day.î D) ìEat fewer orange vegetables and more dark green vegetables daily.î 18. A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status? A) Flat, firm abdomen B) Brittle hair C) Pink mucous membranes D) Elastic skin 19. When obtaining the nutritional health history from a female client, which of the nurse's questions would best elicit information about the client's knowledge of her own health status? A) ìAre you now or have you been on a diet recently?î B) ìHow much fluid do you drink in a day?î C) ìWhat are your height and usual weight?î D) ìCan you tell me what you consider to be a healthy meal?î 20. The nurse needs to obtain the height of a client who is unable to stand. Which of the following would the nurse do? A) Estimate the height while the client is lying in bed. B) Measure the distance from the top of the client's head to his ankles. C) Measure from client's arm span using one of his arms outstretched. D) Extend a ruler from the forehead to the tip of the client's toes.

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    Page 5 21. An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize? A) ìDo you use any over-the-counter dietary supplements?î B) ìAre you familiar with the USDA's MyPlate recommendations?î C) ìHave you ever been diagnosed with heart disease?î D) ìAre you currently taking any diuretic medications?î 22. An older adult client has a body mass index of 15.5 and is consequently considered to be underweight. The client lives alone and states that she has ìnever been a heavy eater.î How can the nurse most accurately assess the client's nutritional habits? A) Assess the client's waist circumference and waist-to-hip ratio. B) Measure the client's mid-arm circumference. C) Elicit the client's 24-hour food recall. D) Have the client describe an ìidealî meal. 23. During a new client's nutritional assessment, the nurse asks the client's height and usual weight. The client states that he has no idea how much he weighs. How should the nurse respond? A) ìDo you feel like your weight has increased, decreased, or stayed the same lately?î B) ìWhy do you feel that it's not important to monitor your weight?î C) ìIn a typical day, what do you eat and drink?î D) ìHow would you describe your feelings around your body type and body mass?î 24. A hospital nurse is performing a nutritional assessment of a 39-year-old obese client who has been recently diagnosed with type 2 diabetes. The nurse has completed the collection of subjective data and is preparing to proceed with objective data collection. Which principle should guide the nurse's subsequent actions? A) There are likely to be inconsistencies between subjective data and objective data. B) The nurse should be aware that the client may find assessment embarrassing. C) The nurse should avoid performing anthropometric measurements due to the client's obesity. D) The assessment should be performed over a series of brief sessions rather than one continuous assessment.

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    Page 6 25. During an initial prenatal visit, the nurse is performing a nutritional assessment of a woman who has just learned that she is pregnant for the first time. The nurse has determined that the client has an average stature and is 5 feet, 3 inches tall. What is this client's ideal body weight? A) 105 lbs. B) 115 lbs. C) 125 lbs. D) 135 lbs. 26. A client's recent complaints of polyuria have prompted a full diagnostic work-up for diabetes mellitus, including a nutritional assessment. To determine the client's body mass index (BMI), the nurse must know which of the following assessment parameters? Select all that apply. A) Gender B) Age C) Weight D) Waist circumference E) Height 27. The nurse is completing a comprehensive nutritional assessment and has assessed and documented the client's triceps skin fold thickness (TSF) using calipers. This assessment finding allows the nurse to determine which of the following? A) The client's ratio of muscle to adipose tissue B) The client's body mass index C) The client's proportion of muscle mass D) The amount of the client's subcutaneous fat stores 28. A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. The nurse has lowered the client's arm and observed how long it takes for venous filling, then raised the same arm and watched how long it takes to empty. After determining that venous filling and emptying each take approximately 10 seconds, the nurse should perform further assessments related to what health problem? A) Fluid volume deficit B) Third spacing C) Ascites D) Malnutrition

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    Page 7 29. The nurse is providing care for a client with a history of chronic heart failure. The client is in bed with the head of her bed at 45 degrees, and the nurse is assessing the client's neck veins. What assessment finding would be most consistent with a nursing diagnosis of fluid volume excess related to chronic heart failure? A) The client's carotid arteries are not palpable. B) The client's jugular veins are clearly visible and firm to palpation. C) The client's carotid pulses are asymmetrical and difficult to palpate. D) The client's carotid pulses are easier to palpate than the jugular pulses. 30. An obese teenage boy from a culture that values increased body mass has been referred to the clinic. The nurse is assessing him for malnutrition based on his electronic health record and current health complaints. His mother questions the nurse's rationale, stating, ìAnyone can see he's not malnourished. Just look at the size of him!î How should the nurse best respond? A) ìPeople sometimes become obese because their bodies are storing up nutrients that they often lack.î B) ìIt's actually very possible for a person to be overweight but have inadequate nutrition.î C) ìAssessment for malnutrition is a standard component of a larger nutritional assessment, which is very important for your son's health.î D) ìActually, there's very little relationship between body mass and nutritional state.î

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    Page 8 Answer Key 1. A 2. A 3. D 4. A 5. C 6. A 7. A 8. D 9. C 10. C 11. A 12. B 13. A 14. D 15. C 16. B 17. B 18. B 19. C 20. C 21. D 22. C 23. A 24. B 25. B 26. C, E 27. D 28. A 29. B 30. B

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    Page 1 1. The nurse is assessing a client's breasts. When assessing the area of the breast most vulnerable to breast cancer, where should the nurse to assess? A) Upper inner quadrant B) Lower inner quadrant C) Upper outer quadrant D) Lower outer quadrant 2. During a prenatal class, a participant says that she was told that her breasts are not large enough to breastfeed. When responding to this client, the nurse should understand that the functional capacity of the breast is primarily determined by which of the following variables? A) Amount of glandular tissue B) Breast size and weight C) Amount of fatty tissue D) Depth of the subcutaneous fat layer 3. The nurse has asked a female client if she has noticed any lumps or swelling in her breasts. After the client responds “yes,” which question should the nurse ask next? A) “Have any of the other women in your family had this happen?” B) “Has there been any corresponding change in your breast size?” C) “Does the lump change over the course of your menstrual cycle?” D) “What do you think is causing this change?” 4. When taking a health history for a female client, which factor should the nurse identify as placing the client at increased risk for breast cancer? A) The client smokes six to eight cigarettes per day B) The client had her first child at age 38 C) The client breast-fed her child for a full year D) The client has a low body mass index 5. Which of the following factors should a nurse include when discussing risk factors about breast cancer for a group of women? A) Early menarche B) One or more pregnancies before age 20 C) Consumption of a high-protein diet D) Early menopause

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    6. While assessing a woman's breasts, the nurse notes a pronounced and asymmetric pattern of veins on the client's breasts. Follow-up care is ordered because the nurse should suspect which of the following? A) Pregnancy B) Fibrocystic changes C) Malignancy D) A low platelet count 7. A 42-year-old female client says she does not perform breast self-examination because she believes that mammograms are more thorough. Which response by the nurse would be most appropriate? A) “You should do the exam. It's the best way to detect breast cancer early.” B) “Be sure to have your breasts checked by a doctor and have a mammogram every year.” C) “Mammograms don't always detect the lumps that you might feel.” D) “Once you hit age 50, you really won't have a choice about doing them.” 8. An 18-year-old woman complains because one breast is larger than the other. What additional interview data would suggest a need for referral? A) The client states that she is sexually active. B) The client states that she does not perform breast self-examination. C) The client states that her problem affects her body image. D) The client states that this represents a sudden change in her breast size. 9. The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. Which of the following would the nurse expect to find? A) Orange-peel skin B) Nipple retraction C) Dark pink areola D) Red and scaling on the areola 10. A woman reports a sudden onset of spontaneous nipple discharge. Which of the following would be the nurse's most appropriate action? A) Refer the client for cytologic study of the discharge. B) Observe the breast for eversion of the nipples. C) Reassure the woman that this is a result of hormonal fluctuations. D) Collect a sample for culture and sensitivity testing.

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    Page 3 11. The nurse is preparing to inspect a woman's breasts for retraction and dimpling. Which position would be most appropriate? A) Standing B) Supine C) Semi-Fowlers D) Sitting 12. A client has large, pendulous breasts. Which of the following would be most appropriate to ensure better access while examining the client's breasts for retraction and dimpling? A) Have the client stand and lean forward B) Have the client lie on her side C) Have the client sit and then lean forward D) Have the client lie flat on her back 13. The nurse is preparing to palpate the breasts of a female client. Which technique should the nurse utilize during this aspect of assessment? A) Use the flat pads of three fingers. B) Use the fingertips of both hands. C) Gently pinch the skin between two fingers. D) Use the palm of one hand. 14. A woman appears restless and is wringing her hands prior to having a clinical breast examination performed. Which statement by the nurse would be most appropriate? A) “I know you are worried, but your risk for cancer is low.” B) “You need to pay attention to these instructions so we can finish as quickly as possible.” C) “You seem to be anxious. Can you tell me what you are thinking?” D) “You appear restless but I can assure you that your doctor is very good.” 15. A nurse has completed the assessment of a client's breasts. The nurse should suspect that the client has fibroadenomas based on which findings? A) Lobular, ovoid, or round lesions B) Irregular, firm cysts C) Round, defined mobile cysts D) Nondefined, mobile cysts

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    16. After teaching a group of young women about breast self-examination, the nurse determines that the teaching was successful when the women state that they will palpate their breasts using which pattern? A) A circular pattern B) A clockwise pattern C) A random pattern D) An up-and-down pattern 17. When palpating a female client's axillae, which of the following actions is most appropriate? A) Have the client hold the arm of the side being examined slightly away from the body. B) Tell the client to raise her arm on the side being examined up over her head. C) Hold the client's elbow of the side being examined with one hand. D) Have the client lean forward from the waist with arms outstretched. 18. When palpating a female client's axillae, which finding would the nurse document as normal? A) Node size is 1.2 cm. B) Nodes are fixed. C) Nodes are hard. D) Nodes are discrete. 19. A nurse is teaching an older adult client about breast self-examination. The nurse includes teaching on expected changes in the client's breasts due to aging. Which of the following would the nurse include? A) Increase in glandular tissue B) Increase in fatty tissue C) Larger nipple area D) Less “granular” in texture 20. A group of students is preparing for a quiz on breast assessment and the assessment findings that are associated with breast cancer. The students demonstrate understanding of the material when they identify which of the following? Select all that apply. A) Irregular, firm lumps B) Elastic, tender, mobile lumps C) Dimpling and nipple retraction D) Orange peel-like appearance E) Redness and warmth with smooth texture F) Breast fullness and pain

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    Page 5 21. A client has presented for care to the clinic, stating, “I'm pretty sure that I feel a new lump in my breast.” After confirming the presence of a lump, what action should the nurse take? A) Arrange for the client to be brought to the hospital emergency department immediately. B) Tell the client to monitor the lump for the next three weeks and seek care if it increases in size. C) Arrange for a prompt referral to her primary care provider. D) Facilitate a referral to an oncologist if more lumps emerge in the coming weeks. 22. A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following? A) “How would you describe your pain? Is it sharp? Is it an ache?” B) “Has the pain changed over time?” C) “Would you describe the pain as being constant or as intermittent?” D) “Is there anything that makes the pain worse or better?” 23. During the health interview, the nurse asks a middle-aged client at what age she began menstruating. This question addresses a risk factor for what health problem? A) Mastitis B) Breast cancer C) Benign breast disease D) Paget's disease 24. The nurse has completed the assessment of a client's breast and lymphatic system. The nurse has ended the assessment by offering to teach the client how to perform breast self-examination (BSE). The client states, “That's alright. I already know how to do that.” What should the nurse do next? A) Encourage the client to perform BSE as often as possible. B) Ask the client to demonstrate BSE. C) Encourage the client to promote BSE to her peers. D) Reiterate the correct technique for BSE. 25. The nurse is beginning the inspection of a young adult client's breasts. The client states, “My left breast has always been a bit bigger than the right.” How should the nurse best respond to the client's statement? A) “Many women have this, and it's rarely a sign of a health problem.” B) “That's very normal, and it usually resolves over time as you get older.” C) “If you lose some weight, the size disparity will likely decrease.” D) “I'll make sure to refer to the doctor to get this assessed further.”

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    26. The nurse is examining a client's breasts and notes the presence of pronounced dimpling. How should the nurse best respond to this assessment finding? A) Confirm whether the client has breast implants in place. B) Ask the client about any history of mastitis (breast infection). C) Explain to the client that this is a normal, age-related change. D) Promptly refer the client for further medical assessment. 27. The nurse is assessing an adult client's areolas and nipples. What assessment finding would most clearly warrant referral? A) Small Montgomery tubercles are present on the areolas. B) Supernumerary nipples are present. C) The patient's nipple has recently become inverted. D) The patient's areola puckers upon palpation. 28. The nurse is palpating the axillary lymph nodes of a client who has been experiencing recent malaise. The nurse should consider a lymph node to be enlarged if its diameter exceeds what size? A) 0.5 cm B) 1 cm C) 2 cm D) 2.5 cm 29. In which of the following male clients would gynecomastia be considered to be an expected assessment finding? A) A 14-year-old boy who began puberty last year B) An older adult who takes antihypertensive medications C) A 59-year-old man who has been exposed to heavy metals in the workplace D) A male client who has been diagnosed with breast cancer 30. Assessment of a client's breasts reveals tenderness on palpation and diffuse redness. What collaborative problem is most clearly suggested by these data? A) RC: Breast cancer B) RC: Benign breast disease C) RC: Hematoma D) RC: Infection

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    Page 7 Answer Key 1. C 2. A 3. C 4. B 5. A 6. C 7. B 8. D 9. D 10. A 11. D 12. C 13. A 14. C 15. A 16. D 17. C 18. D 19. B 20. A, C, D 21. C 22. A 23. B 24. B 25. A 26. D 27. C 28. B 29. A 30. D

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    Page 1 1. To examine the Bartholin's glands of a female client, the nurse would palpate at which anatomic location? A) On both sides of the clitoris B) Just inside the urethral orifice C) Between the vaginal opening and labia minora D) Inside the vaginal orifice 2. During the health history, a postmenopausal client mentions that she is experiencing vaginal dryness. When explaining the most likely reason to the client, the nurse should explain the role of which hormone? A) Estrogen B) Progesterone C) Follicle-stimulating hormone (FSH) D) Oxytocin 3. A client's health history reveals that she had a total hysterectomy at age 33 to treat severe endometriosis. She says that the surgeon also removed both ovaries and fallopian tubes. The nurse would interpret this as which of the following? A) Natural menopause B) Delayed menopause C) Premature menopause D) Artificial menopause 4. An older adult client states, ìSometimes when I sneeze, I notice that I wet my pants.î The nurse interprets this as which of the following? A) Reflex incontinence B) Stress incontinence C) Urge incontinence D) Total incontinence 5. A postmenopausal woman tells the nurse that she experiences discomfort during sexual intercourse. Which of the following should the nurse suggest? A) Use of a lubricant B) Abstinence from intercourse C) Use of a condom by the partner D) Kegel exercises

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    Page 2 6. A young female client refuses treatment for a sexually transmitted infection. The nurse explains that lack of treatment may put her at risk for which condition? A) Endometriosis B) Urinary tract infection C) Cervical cancer D) Pelvic inflammatory disease 7. A client has been to the clinic multiple times in the past year with vaginal infections, the most frequent of which was candidiasis. The nurse would assess the client for symptoms most likely related to which condition? A) Intestinal parasites B) Urinary tract infections C) Hypothyroidism D) Diabetes mellitus 8. During the health history, the nurse teaches a client about toxic shock syndrome and ways to reduce her risks. The nurse determines that the teaching was successful when the client states which of the following? A) ìI will get a Pap smear regularly.î B) ìIt is important to use latex condoms.î C) ìI should change tampons at least every 4 to 6 hours.î D) ìI should stop using oral contraceptives.î 9. When assessing the vaginal orifice of a young female client who has never been sexually active, the nurse notes a fold of fibrous tissue at the introitus. The nurse recognizes this as which structure? A) Labia B) Urethra C) Hymen D) Clitoris 10. When palpating the Bartholin's glands, the nurse expresses a purulent discharge. Which of the following would be most appropriate for the nurse to do next? A) Recommend sitz baths. B) Palpate the uterus. C) Obtain a culture. D) Perform a rectal exam.

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    Page 3 11. The nurse notes a malodorous, yellow discharge upon inserting the speculum into the client's vagina. Which of the following should the nurse do next? A) Obtain a urine specimen. B) Obtain a wet mount slide. C) Procure a Papanicolaou (Pap) smear. D) Perform a bimanual exam. 12. The nurse is presenting a class to a group of high school students about sexually transmitted infections. Which of the following should the nurse include as a major risk factor for cervical cancer? A) Gonorrhea B) Chlamydia C) Syphilis D) Human papilloma virus 13. When obtaining a cervical specimen for a Neisseria gonorrhoeae culture, which of the following would be most appropriate? A) Wipe the cotton-tipped applicator onto a slide. B) Spread the specimen in a ìZî pattern on a special culture plate. C) Immerse the swab in a liquid medium and refrigerate. D) Roll the endocervical brush onto a slide. 14. The nurse is inspecting the client's vaginal musculature and asks the client to bear down. Which finding would lead the nurse to suspect that the client has a cystocele? A) Bulging of the anterior vaginal wall B) Protrusion of the cervix C) Urine leakage D) Protrusion at the back of the vaginal wall 15. The nurse is preparing to perform a speculum examination on a client. The nurse lubricates the speculum with which of the following? A) Petroleum jelly B) Water-soluble lubricant C) Client's vaginal secretions D) Antimicrobial ointment

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    Page 4 16. The nurse is inspecting the cervix of a client who has two children. The nurse would expect the cervical os to appear as which of the following? A) Round B) Slit-like C) Transverse D) Stellate 17. When assessing the cervix of an older postmenopausal woman, which of the following would the nurse document as a normal finding? A) Bluish color B) Bright red C) Pale pink D) White patches 18. The nurse is assessing a female client's genitourinary system. Which of the following findings would lead the nurse to suspect a problem with the ovaries during palpation? A) Slight tenderness on palpation B) Walnut-sized ovaries C) Immobile ovaries D) Smooth ovarian surface 19. The nurse is preparing to perform a rectovaginal examination on a client. Which statement by the nurse would be most appropriate? A) ìI have to do this exam to make sure everything is okay, so just bear with me.î B) ìYou might feel uncomfortable, almost like you have to move your bowels.î C) ìJust relax, it will only take a minute and then I'll be all finished.î D) ìI want you to hold your breath as I insert my fingers into the openings.î 20. While inspecting the vagina, the nurse observes a thin, grayish-white vaginal discharge with a fishy odor. Which of the following would the nurse suspect? A) Moniliasis B) Trichomoniasis C) Bacterial vaginosis D) Atrophic vaginitis

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    Page 5 21. A 49-year-old woman has sought care because of severe perimenopausal symptoms. The client has asked the nurse if she should talk to her doctor about beginning hormone replacement therapy (HRT). How should the nurse best respond? A) ìThe most recent research suggests that the benefits of HRT have been greatly overstated.î B) ìHRT often relieves many of the symptoms of menopause, but it's not without some risks.î C) ìHRT is a good option for many women, mostly because it's a naturally occurring substance.î D) ìYour doctor will likely recommend HRT because you're beginning menopause quite young.î 22. A 52-year-old woman's current medication regimen includes estrogen-progestin therapy (EPT). In addition to reduced symptoms of menopause, the nurse should be aware that this therapy confers what secondary benefit? A) Weight loss B) Reduced risk of colorectal cancer C) Protection against stroke D) Increased libido 23. A female client has presented for a Pap smear test, and the nurse is discussing risk factors for cervical cancer. What risk factor should the nurse describe? A) Having multiple sexual partners B) Previous treatment for chlamydial infection C) Pregnancy before age 21 D) African-American ethnicity 24. The nurse is completing a client's genitourinary assessment and is preparing to assess the client's cervix. What finding would most clearly warrant referral? A) The cervix is firm on palpation. B) The cervix is immobile on palpation. C) The cervix is smooth and pink on inspection. D) The cervix projects 2 cm into the client's vagina. 25. Scar tissue is visible on the perineum of an adult female client. The nurse should consequently question the client about which of the following? A) Surgical correction of a rectocele B) History of sexually transmitted infections C) History of sexual abuse D) Tearing during vaginal delivery

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    Page 6 26. In which of the following clients would the nurse consider a bluish tint to the cervix an expected assessment finding? A) A client who is 17 years old and sexually active. B) A client who is 10 weeks' pregnant. C) A 71-year-old multiparous client D) A client who has a 24 pack-year smoking history. 27. The nurse is assessing the genitalia and rectum of a 71-year-old client. When assessing the client's vagina, the nurse should know that age-related changes increase the client's risk of what abnormal finding? A) Trichomonas vaginitis B) Bacterial vaginosis C) Candidal vaginitis D) Atrophic vaginitis 28. A nurse is preparing a female client for a genitourinary examination that has been scheduled for later in the week. What anticipatory guidance should the nurse provide to the client? A) ìStop taking any antibiotics for 24 hours before your examination.î B) ìMake sure not to douche for 48 hours before the examination.î C) ìDon't bathe or shower on the morning of the appointment.î D) ìDrink at least 48 ounces of fluid the morning before the appointment.î 29. The nurse is preparing a client for an assessment of her genitalia and rectum. What action should the nurse perform when preparing the client? A) Assist the client into a prone position. B) Explain the rationale for using foot stirrups. C) Reassure the client that no one other than the nurse will be in the room. D) Obtain written, informed consent for the examination. 30. An adult client has sought care at the clinic, stating that she believes she has ìa raging yeast infection.î The nurse would expect to assess what type of vaginal discharge? A) Thick, white vaginal discharge B) Copious clear, foul-smelling discharge C) Yellowish discharge with a metallic odor D) Blood-tinged vaginal discharge

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    Page 7 Answer Key 1. C 2. A 3. D 4. B 5. A 6. D 7. D 8. C 9. C 10. C 11. B 12. D 13. B 14. A 15. C 16. B 17. C 18. C 19. B 20. C 21. B 22. B 23. A 24. B 25. D 26. B 27. D 28. B 29. B 30. A

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    Page 1 1. A nurse is performing an assessment within the legal parameters of assessment and diagnosis. These legal guidelines would be specified in which of the following? A) The state's Nurse Practice Act B) The client's informed consent documents C) The nurse's terms of license D) The institution's policies and procedures guidelines 2. When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which of the following principles? A) The client has the right to refuse the assessment. B) Obtaining permission enhances therapeutic rapport. C) The client will be more willing to disclose after giving permission. D) The client's level of comfort will be increased by granting explicit consent. 3. The nurse is completing the general survey. In addition to observing the client's appearance, the nurse would assess which of the following? A) Mental status B) Cognitive abilities C) Vital signs D) Thought processes 4. A novice nurse is practicing how to complete a comprehensive assessment to gain confidence and skill. Which of the following would be most important for the nurse to remember? A) Always gather objective data before subjective data. B) Intersperse the physical exam with the history. C) Establish a routine for the assessment. D) Allow the client a break between the two parts of the history/exam. 5. When analyzing data related to a client's behavior, the nurse should compare the observations with which of the following? A) The client's developmental stage B) The client's motivation for change C) The client's body mass index D) The client's vital signs

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    Page 2 6. When performing a client's head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII? A) Mental status examination B) Head and face assessment C) Ears assessment D) Examination of mouth and throat 7. When documenting a comprehensive assessment, which statement would the nurse record as the reason for seeking health care? A) ìI try not to let the pain affect my life.î B) ìI haven't had a checkup in over 5 years.î C) ìI had my appendix removed when I was 14 years old.î D) ìI have an aunt who had breast cancer.î 8. The nurse would test for stereognosis during which part of the comprehensive exam? A) Posterior and lateral chest B) Nose and sinuses C) Arms, hands, and fingers D) Legs, feet, and toes 9. A nurse has finished examining a client's nose and sinuses and is about to examine the client's mouth and throat. Which of the following would be most important for the nurse to do? A) Warm the hands B) Put on gloves C) Obtain a tuning fork D) Collect a saliva specimen 10. When assessing a client's mental status, which of the following would the nurse assess? Select all that apply. A) Remote memory B) Coping skills C) Speech D) Abstract reasoning E) Judgment

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    Page 3 11. The nurse is performing a head-to-toe assessment of a client. Which of the following would be an example of information obtained during the review of the client's body systems? A) Wears dentures; denies problems with eating, chewing, and swallowing. B) States her father died of a heart attack at age 70. C) Uses over-the-counter antacid for occasional heartburn. D) Vaginal delivery of two children without complications. 12. A nurse is preparing to complete a comprehensive health assessment on a female client. Prior to beginning the assessment, the client states, ìI'm really having a good deal of pain in my hip now.î Which of the following would be most appropriate for the nurse to do? A) Begin the comprehensive assessment and aim to complete it efficiently. B) Explain the reason for the client's assessment. C) Delay the full exam until the client's pain has been addressed. D) Provide education on pain control. 13. A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available? A) Ophthalmoscope B) Tuning fork C) Facial tissues D) Stethoscope 14. A nurse should assess the client's epitrochlear lymph nodes when assessing which of the following? A) Neck B) Arms C) Posterior chest D) Sinuses 15. The nurse will palpate a client's axillae during a head-to-toe assessment. The nurse should combine this with examination of which area? A) Neck B) Anterior chest C) Heart D) Breasts

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    Page 4 16. The nurse is palpating the client's tonsillar, submandibular, and submental lymph nodes. The nurse is most likely examining which area during a comprehensive assessment? A) Nose and sinuses B) Abdomen C) Neck D) Face 17. During which part of the comprehensive assessment would the nurse auscultate after inspecting but before percussing? A) Abdomen B) Anterior chest C) Neck D) Heart 18. When assessing the client's legs, feet, and toes, which pulses would the nurse expect to palpate? Select all that apply. A) Femoral B) Brachial C) Temporal D) Dorsalis pedis E) Popliteal F) Posterior tibial 19. The nurse is documenting findings of a comprehensive assessment. Which statement would be categorized as part of the general survey? A) Hair neat and clean with white and gray streaks; no scalp lesions noted B) Sclera white; conjunctiva slightly reddened without lesions C) Client alert and cooperative; sitting comfortably on chair with hands in lap D) Head symmetrically round; neck nontender with full range of motion 20. A nurse is preparing to complete a comprehensive assessment on a client. When collecting objective data, which of the following should the nurse do first? A) Assess the client's vital signs. B) Take the client's body measurements. C) Assess the client's mental status. D) Observe the client's overall appearance.

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    Page 5 21. The nurse is preparing to perform a comprehensive assessment of a client who has a diagnosis of Alzheimer's disease. How should the nurse accommodate the client's cognitive deficit when obtaining the client's health history? A) Obtain the client's history from the electronic health record and proceed with physical assessment. B) Focus the assessment on aspects of the client's history that he is able to accurately describe. C) Perform the assessment as quickly as possible in order to minimize the client's stress. D) Supplement the client's statements with data from the client's friends and family. 22. The nurse is preparing to gather equipment prior to a client's head-to-toe assessment. The nurse's selection of equipment should be based primarily on what variable? A) The nurse's time allowance B) The nurse's level of expertise C) The client's health needs D) The client's level of participation 23. The nurse is performing an abbreviated head-to-toe assessment of a hospital client. What question should the nurse ask when assessing the client's level of consciousness? A) ìIf there were a fire in your house, what would you do?î B) ìHow would you describe your overall level of stress?î C) ìCan you tell me the current month and year?î D) ìCan you tell me what you ate for breakfast this morning?î 24. The nurse is performing an abbreviated head-to-toe assessment of a client. When the nurse asks the client about his pain, the client states, ìMy stomach's really killing me right now.î How should the nurse first respond to this client's statement? A) Offer analgesia to the client B) Ask the client to rate his pain on a 0-to-10 scale C) Assess the client's level of consciousness D) Assure the client that his pain will be addressed immediately following the assessment 25. The nurse is completing an abbreviated head-to-toe assessment of a client. Which of the following should the nurse perform when assessing the client's eyes? A) Test the client's pupillary response to light. B) Test the client's visual fields. C) Perform the cover test. D) Test the client's vision.

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    Page 6 26. A client has been recovering from surgery in the hospital, and the nurse is beginning a shift by conducting an abbreviated head-to-toe assessment. How should the nurse assess the client's bowel sounds? A) Auscultate for 2 to 3 minutes in the client's right upper abdominal quadrant. B) Auscultate for bowel sounds in each of the client's four abdominal quadrants. C) Auscultate for 5 minutes to confirm the presence of consistent bowel sounds. D) Auscultate to determine which quadrant contains the most active bowel sounds. 27. The nurse is planning the comprehensive head-to-toe assessment of a client. What assessment should the nurse usually conduct last? A) Assessment of the abdomen B) Assessment of the genitalia and rectum C) Assessment of the lower extremities D) Assessment of the posterior thorax 28. The nurse is using the COLDSPA mnemonic during the client's head-to-toe assessment. This tool will allow the nurse to address what component of assessment? A) The client's present health concern B) The review of the client's body systems C) The client's personal health history D) The client's health practices profile 29. The nurse is assessing a client's judgment during a comprehensive head-to-toe assessment. How can the nurse best appraise this aspect of cognitive function? A) ìWhat would you do if you found a stamped, addressed envelope on the ground?î B) ìWhat kinds of activities do you do to improve your health?î C) ìWho is the most important person in your life, and why?î D) ìWhat is your idea of the ideal vacation?î 30. The nurse should ensure that a Doppler ultrasound is available when performing which of the following assessments? A) Respiratory assessment B) Peripheral vascular assessment C) Abdominal assessment D) Musculoskeletal assessment

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    Page 7 Answer Key 1. A 2. A 3. C 4. C 5. A 6. B 7. B 8. C 9. B 10. A, C, D, E 11. A 12. C 13. B 14. B 15. D 16. C 17. A 18. A, D, E, F 19. C 20. D 21. D 22. C 23. C 24. B 25. A 26. B 27. B 28. A 29. A 30. B

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    Page 1 1. A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? A) Establishing a trusting relationship B) Determining the client's strengths C) Identifying potential health problems D) Making clinical inferences 2. A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview? A) Introductory B) Working C) Summary D) Closing 3. A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental? A) “How often do your adult children typically visit you?” B) “Your husband's death must have been very difficult for you.” C) “You must quit smoking because it affects others, not only you.” D) “How would you describe your feelings about getting older?” 4. A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? A) Standing while the client is seated B) Using a moderate amount of eye contact C) Sitting across the room from the client D) Minimizing facial expressions 5. A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement? A) “Tell me about your relationship with your children?” B) “Tell me what you eat in a normal day?” C) “Are you allergic to any medications?” D) “What is your typical day like?”

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