ANS (VNSG 2431) CH. 13 "Physical Assessment" NCLEX-STYLE QUESTIONS || All Correct.
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ANS CH. 13 \"Physical Assessment\" NCLEX
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ANS CH. 13 \"Physical Assessment\" NCLEX
During the assessment of a client, the nurse places a paper towel on the weighting scale before the client stands barefoot on it. What is the purpose of this intervention by the nurse?
A) To overcome chances of zero error in the equipment
B) To ensure that the weight obtained is accurate
C) To...
ANS (VNSG 2431) CH. 13 "Physical Assessment" NCLEX-
STYLE QUESTIONS || All Correct.
During the assessment of a client, the nurse places a paper towel on the weighting scale before
the client stands barefoot on it. What is the purpose of this intervention by the nurse?
A) To overcome chances of zero error in the equipment
B) To ensure that the weight obtained is accurate
C) To provide a rough approximation of the gross body weight
D) To reduce contact with microorganisms on the equipment correct answers D) To reduce
contact with microorganisms on the equipment
A paper towel is placed on the scale before the client stands barefoot on it to reduce contact with
microorganisms on the equipment that other people use. The scale needs to be calibrated to zero
to ensure that the client's weight is measured accurately and there is no chance of zero error. The
paper towel does not help to overcome the chances of zero error in the equipment. A heavier
weight is positioned in a calibrated groove of the scale arm to provide a rough approximation of
the gross body weight.
The nurse is assessing a client's hearing acuity. During the voice test, the nurse stands
approximately 2 feet behind and to the side of the client. Why should the nurse take this position
during the voice test?
A) To facilitate sound conduction to the tested ear only
B) To simulate the distance between people during social interaction
C) To assess the client's ability to discriminate sound
D) To deliver a high-pitched sound toward the tested ear correct answers B) To simulate the
distance between people during social interaction
The nurse stands 2 feet behind and to the side of the client while performing a voice test for
hearing acuity to stimulate the distance between people during a social interaction; this will
prevent the client from observing visual cues. Instructing the client to cover the ear on the
opposite side allows assessment of sound conduction to the tested ear only. Whispering numbers,
colors, or names toward the uncovered ear delivers a high-pitched sound, the most common type
of hearing loss, toward the tested ear. Asking the client to repeat the whispered word allows the
nurse to assess the client's ability to discriminate sound.
A client is brought to the health care center in a semi-conscious state following a suicide attempt.
The nurse is assisting the physician in resuscitating the client. The client's skin appears to be
bluish. What should the nurse document as the cause for this coloration?
A) Carbon monoxide poisoning
B) Trauma to soft tissue
C) Anemia due to blood loss
D) Low tissue oxygenation correct answers D) Low tissue oxygenation
, The nurse should document low tissue oxygenation as the cause for this coloration, called
cyanosis. The skin would appear pale due to blood loss and anemia, red due to carbon monoxide
poisoning, or purple due to trauma to soft tissues.
When assessing the sounds of a client's lungs, the nurse asks the client to breathe in and out
through an open mouth, deeply but slowly. How does this intervention help in the assessment?
A) It reduces sound from air turbulence and prevents hyperventilation
B) It helps to clear the air passages and open the alveoli
C) It ensures that characteristics during each phase of ventilation is heard
D) It facilitates hearing sounds in the upper and lower lobes correct answers A) It reduces sound
from air turbulence and prevents hyperventilation
The nurse instructs the client to breathe in and out through an open mouth, deeply but slowly, to
reduce the sound from air turbulence and prevent hyperventilation. When crackles and gurgles
are audible during the assessment, the nurse may ask the client to cough or breathe deeply
because it helps to clear the air passages and open the alveoli. The nurse should avoid placing the
chest piece over the scapulae or ribs when applying the chest piece to the upper back to facilitate
hearing sounds in the upper and lower lobes. The nurse listens for one complete ventilation
(inspiration and expiration) at each area auscultated to ensure that characteristics during each
phase of ventilation are heard.
The nurse conducting a physical assessment can encourage the client to be honest and open in
identifying the health problem by:
A) Offering the client an opportunity to ask questions.
B) Explaining that all information will be kept confidential
C) Explaining the assessment technique before performing it
D) Explaining how the assessment will be conducted correct answers B) Explaining that all
information will be kept confidential
To encourage the client to be honest and open in identifying the health problem, the nurse should
explain that all information collected during the assessment would be kept confidential among
those involved in the client's care. By explaining, before performing it, the assessment technique
and how the assessment will be conducted, the nurse tries to reduce the anxiety of the client. By
offering the client the opportunity to ask questions, the nurse encourages active participation in
learning and decision making.
A nurse conducting physical assessment for a client using the percussion technique. What is the
purpose of using this technique?
A) To check the skin temperature and moisture
B) To assess the mobility of normal tissues and unusual massess
C) To determine the location, size, and density of underlying structures
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