Final Exam 264 Test Questions And 100% Correct Answers.
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Course
NURS 264
Institution
NURS 264
An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should ...
Final Exam 264 Test Questions And
100% Correct Answers.
An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at
the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along
with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the
nurse do next before proceeding? - Answer Ask for the client's permission to perform the assessment
A nurse should use light palpation of the abdomen to obtain objective data about which characteristic of
the abdomen? - Answer Abdominal reflex
The nurse will obtain the greatest amount of information about the thyroid gland by using which
technique of assessment? - Answer Palpation
A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on
gloves? - Answer Just before the mouth and throat assessment
During which part of a head-to-toe physical examination should the nurse palpate the epitrochlear
lymph nodes? - Answer Arms, hands, and fingers The epitrochlear lymph nodes are found on the inside
of the upper arm, just above the elbow.
The nurse has reviewed the previous physical assessment notes on a client and sees the following
documentation: PERRLA, L 6-4, R 6-4. What is the nurse's best action for follow-up care on this client? -
Answer Re-assess as needed
What symptom(s) found during assessment would cause the nurse to suspect the client may be
experiencing sepsis? Select all that apply. - Answer Temperature greater than 102 °F (38.9 °C)
Respiratory rate 36 breaths per minute
Altered mental state
Documented or suspected infection
,In order to assess a client's abdominal reflexes, what should the nurse include in the physical
examination? - Answer light stroking inward from all quadrants
In order to conduct an examination of the eye muscles, the nurse should prepare to administer which
tests? Select all that apply. - Answer six cardinal directions of gaze
convergence
near reaction
cover-uncover test
The nurse wants to assess a client's 5th cranial nerve. What approach should be used? - Answer stroke
each side of the cheek with a cotton wisp
Students are learning about subjective data collection. What data are collected subjectively? (Mark all
that apply.) - Answer Risk factors
Common symptoms
Family history
A nurse is performing a part of a physical assessment for a client using palpation. What is the purpose of
using this technique? - Answer To check the skin temperature and moisture.
A nurse is assessing a client who seems to have developed a hearing impairment after working at a
construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity.
Weber's test does which of the following? - Answer Determines the equality or disparity of bone-
conducted sound.
A nurse is preparing a client for a head-to-toe examination. Which of the following should the nurse do
at this time? Select all that apply. - Answer Discuss the purpose and importance of the health history
with the client
Acquire the client's permission to ask personal questions
Explain your respect for the client's privacy and confidentiality
Explain that the client will need to change into a gown
,When performing a shift assessment, the nurse identifies the client has on a sequential compression
device. What must the nurse then assess? - Answer Skin
A 54-year-old man is found to be anemic. Which of the following nursing diagnosis is most likely to be
recorded in his plan of care? - Answer Fatigue
A client with congestive heart failure presents to the emergency department with soreness from swelling
of the ankles. When conducting the physical examination of this client, the nurse would require a
stethoscope for which reason? - Answer to auscultate the lungs
The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass.
The client grimaces and grips the handrails of the bed. Which response by the nurse is best? - Answer
"We can take a break anytime."
When inspecting the face for facial symmetry, what would the nurse have the client do? (Select all that
apply.) - Answer Raise eyebrows
Frown
Smile
Close eyes
The nurse completes the assessment of a client's heart. What should be assessed next? - Answer
Breast
When examining a client's musculoskeletal system, for which assessment should the client be in a seated
position? - Answer elbow flexion
During the general survey a client comments about the extremely cold weather even though the client
lives in a major northeastern United States city and the month is July. What action should the nurse
take? - Answer assess mental status
The nurse is conducting a head-to-toe assessment on a client. Which body systems are typically
integrated throughout the entire assessment? Select all that apply. - Answer Neurologic
Musculoskeletal
, The nurse suspects that a client has an infection of the lower leg. What skin assessment finding caused
the nurse to make this clinical determination? Select all that apply. - Answer Warmth
Erythema
A nurse performs the Mini-Mental Status Exam to assess cognitive abilities of a client. What will the
nurse assess as a part of the Mini-Mental Status Exam? - Answer Remote memory of the past
The nurse identifies during assessment that the client is at risk for the development of pressure ulcers.
What findings did the nurse identify? Select all that apply. - Answer Moisture
Poor nutrition
Altered sensory perception
Prior to conducting a mental status exam with a client who has a diagnosis of depression, the nurse can
obtain that information by observing the client? - Answer grooming
affect
Posture
The nurse is conducting a physical examination of a client who has congestive heart failure. The general
survey can provide the nurse with which information? - Answer edema of the face and limbs
presence of cyanosis
respiratory rate
A client turns the head to the right after the nurse whispers the direction to do so in the client's left ear.
What information should the nurse obtain from the client's response? - Answer cranial nerve VIII is
intact Responding appropriately to the "whisper test" assesses cranial nerve VIII.
When should the nurse assess the costovertebral angle for tenderness? - Answer after assessing the
posterior thorax
When collecting subjective data, the nurse gives the client time and encouragement to do what? -
Answer Tell about the client's concerns
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