1. During the interview portio of the health assessment, a nurse notes the
person's posture, physical appearance, and ability to converse. How
should the nurse document these findings? - ANS -Objective.
2. As a part of a routine health assessment, the nurse assesses the kidneys
as part of the abdominal assessment. Which assessment finding should
the nurse conclude is normal when palpating the client's right kidney? -
ANS -A round smooth mass that slides between the fingers
3. When teaching a client how to perform a monthly breast self-assessment,
the nurse should tell the client that it is most important to assess which part of the
breast more closely for changes? - ANS -Upper outer quadrant.
4. The nurse is completing a physical exam on an adult client. Which thyroid
finding is considered normal? - ANS -Gland is not palpable
5. The nurse is assessing a client's middle lung lobe. What is the best
location for the nurse to place a stethoscope diaphragm to hear normal
, lung sounds in this lobe? - ANS -4th intercostal space, right midclavicular line.
Correct
6. While performing a head-to-toe assessment, the nurse assesses the client's
pupillary accommodation. During the second portion of the test, the nurse notes
that the client's pupils constrict and there is convergence of the axes of the eyes.
What action should the nurse implement next? - ANS -Document a normal
finding.
7. The nurse is performing a head-to-toe assessment on a client. The nurse is
assessing the client's pupillary light reflex by first darkening the room and asking
the person to gaze into the distance. Then, the nurse advances a light toward
one eye from the client's side. What would the nurse expect to see at this time? -
ANS -A consensual response in the opposite eye.
8. A client presents with a rash along the occipital area of the hairline and
reports intense itching. How should the nurse begin the objective part of
the examination? - ANS -Inspect the scalp looking for nits
9. A client has come to the clinic for a routine health assessment. What is the
best assessment question for the nurse to ask a client after observing
tophi on the client's ear cartilage? - ANS -Have you had sudden and severe
pain in the toes or feet?
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