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11)A nurse places a client with advanced metastatic cancer in

11)A nurse places a client with advanced metastatic cancer in the lateral position to begin percussion of the abdomen. What finding would the nurse expect in this situation? 1)Tympany at the superior level and dullness at lower levels 2)Tympany throughout the abdomen 3)Dullness over all abdominal organs 4)Dullness at superior level and tympany at.
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11)A nurse places a client with advanced metastatic cancer in
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11)Mr. Barton, 52 years old, scheduled for a prostatectomy. What

11)Mr. Barton, 52 years old, is scheduled for a prostatectomy. What assessment finding might the nurse observe in Mr. Barton? 1)Enlargement of the scrotal sac 2)Decrease in prostatic specific antigen (PSA) 3)Lower back pain 4)Difficulty in initiating urine stream 12)The mother of a toddler expresses concern over her son “constantly playing with his penis and.
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11)Mr. Barton, 52 years old, scheduled for a prostatectomy. What
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21)A nurse performing a complete assessment a 6-year-old child who

21)A nurse is performing a complete assessment on a 6-year-old child who was admitted for abdominal pain.  When asking about pain, which statement would be expected to elicit the most detailed information? 1)“Can you tell me about your abdominal pain?” 2)“Tell me where your tummy hurts right now.” 3)“Can I feel your tummy.
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21)A nurse performing a complete assessment a 6-year-old child who
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse notes edema in bilateral knees in an elderly client.  The client has complaints of joint stiffness and pain upon awakening.  What disorder would the nurse suspect based on this data? 1)Rheumatoid arthritis 2)Osteoarthritis 3)Gouty arthritis 4)Tendonitis 2)A nurse is.
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MULTIPLE CHOICE.  Choose the one alternative that best completes the
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse is interviewing a primigravida client who is 14 weeks pregnant and reports she has not felt the baby move yet.  How should the nurse respond?? 1)“You need an ultrasound.” 2)“Have you lost a baby before?” 3)“We will.
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31)  What stratum the outermost layer of epidermis the soles

31)  What stratum is the outermost layer of epidermis on the soles of the feet? 1)  Basale 2)  Granulosum 3)  Germinativum 4)  Corneum 32)  Ms. Dhalliwal, 22 years old, has recently moved to Canada from India. She has white skin and pale blond hair. How should the nurse document Ms. Dhalliwal’s appearance? 1)  Pallor 2)  Vitiligo 3)  Tinea.
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31)  What stratum the outermost layer of epidermis the soles
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1) A nurse is assessing the pulse behind the client’s knee.  What is the name of this pulse? 1)Brachial 2)Dorsalis pedis 3)Popliteal 4)Posterior tibial 2)A nursing student is assessing the carotid pulses of a client.  What action by the student would.
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11)A nurse caring for an immobile client and planning care

11)A nurse is caring for an immobile client and is planning care to prevent vascular complications that may occur.  What would the nurse include in the plan of care? 1)Meticulous skin care 2)Turn, cough, deep breath 3)Physical therapy for tolerated activity 4)Increased protein intake 12)During an assessment of a client's hand the nurse observes: flattening.
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11)A nurse caring for an immobile client and planning care
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse is interviewing an elderly client who reports having incontinence. Numerous attempts have been made in the recent past to help control the problem, with no success. What is a priority nursing diagnosis to consider.
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21)A 76-year-old client presents to the ambulatory care clinic with

21)A 76-year-old client presents to the ambulatory care clinic with concerns consistent with influenza.  During the interaction, the nurse notes the client appears unkempt.  The client’s hair is uncombed and the clothing appears too large.  What would the nurse do next? 1)Document the findings. 2)Engage the client in a discussion regarding dietary.
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21)A 76-year-old client presents to the ambulatory care clinic with
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21)A nurse preparing to examine a male client’s reproductive organs.

21)A nurse is preparing to examine a male client’s reproductive organs. What should the nurse do in preparation for this examination? 1)    Use clean hands for the examination 2)Ask the client to lie down on the examination table 3)   Ensure the room’s temperature is cool and comfortable 4)Ask the client to empty his bladder 22)A.
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21)A nurse preparing to examine a male client’s reproductive organs.
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)Ms. Delmonte, 30 years old, tells the nurse she has a non-painful lump on her left wrist. The nurse notes a round mass on the back of the wrist.  What condition should the nurse suspect? 1)Rheumatoid arthritis 2)Osteoarthritis 3)Ganglion 4)Carpal.
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse is examining the external genitalia of a female client and notes raised, cauliflower-shaped papules.  What conclusion can the nurse make based on these findings? 1)Genital warts 2)Herpes infection 3)Bartholin’s abscess 4)Contact dermatitis 2)A nurse suspects a gonorrheal infection in.
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MULTIPLE CHOICE.  Choose the one alternative that best completes the
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Chapter 12 MULTIPLE CHOICE.  Choose the one alternative that best completes

Chapter 12 MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse is palpating an adult client’s neck and is unable to palpate any lymph nodes. How will the nurse interpret this finding? 1)Probably due to an infection 2)Cause to inspect for further malformations 3)A normal finding in.
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Chapter 12 MULTIPLE CHOICE.  Choose the one alternative that best completes
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21) A nurse performing a gynecological examination and ready to

21) A nurse is performing a gynecological examination and is ready to insert the speculum into the vagina.  How should the nurse insert the speculum? 1)90 degree angle 2)45 degree angle 3)Straight down 4)Straight up 22)A nurse is performing a vaginal examination, which includes a cervical scrape, on a client who has had a hysterectomy. .
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21) A nurse performing a gynecological examination and ready to
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse notes in the physical exam done by the physician that the client has a positive Romberg.  What should the nurse do to help the client meet elimination needs? 1)Provide a bedside commode 2)Allow the client to.
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11)A nurse assessing the eyes of an 82-year-old client.  What

11)A nurse is assessing the eyes of an 82-year-old client.  What age related physiologic change should the nurse anticipate? 1)Thin, yellow lens 2)Larger size pupils 3)Quicker pupillary light reflexes 4)Decrease in lacrimal secretions 12)A nurse will be giving a distance visual acuity test to a 3- year-old child. What type of chart will be required.
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11)A nurse assessing the eyes of an 82-year-old client.  What
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11)A nurse assessing the patellar reflex a client and obtains

11)A nurse is assessing the patellar reflex on a client and obtains no reflexive activity.  The client is alert and oriented.  What should the nurse do first? 1)Document the findings as normal 2)Notify the physician immediately 3)Look at the medication records for central nervous system depressants 4)Retest the reflex but use a distraction technique.
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11)A nurse assessing the patellar reflex a client and obtains
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse is assessing a client with Parkinson’s disease.  What type of tremors would the nurse observe? 1)Fasciculations 2)Chorea 3)Rhythmic shaking 4)Athetoid movements 2)A nurse notes that a client has difficulty with ambulation due to an unsteady gait.  The client uses.
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21)A nurse interviewing Mrs. Davis, who states she has urinary

21)A nurse is interviewing Mrs. Davis, who states she has urinary incontinence with coughing and sneezing.  How should the nurse document this type of incontinence? 1)Functional 2)Reflex 3)Stress 4)Urge 22)What is the landmark for palpating the kidneys through the abdominal wall? 1)Costoverterbral angle 2)Symphysis pubis 3)Iliac crests 4)Rectus abdominis 23)A nurse is auscultating the renal arteries on a 15-year-old client.
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21)A nurse interviewing Mrs. Davis, who states she has urinary
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11)A nurse notes full range of motion against gravity with

11)A nurse notes full range of motion against gravity with full resistance when assessing muscle strength of the upper extremities in a client.  How should the nurse document this finding? 1)Poor 2)Normal 3)Fair 4)Good 12)A nurse notes swelling and tenderness of the olecranon process during palpation.  The client’s chief complaint is pain upon movement of.
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11)A nurse notes full range of motion against gravity with
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11)A nurse listening to heart sounds a 19-year-old client. The

11)A nurse is listening to heart sounds on a 19-year-old client. The nurse notes a splitting of S2 at the end of inspiration. How should the nurse interpret this assessment finding? 1)A normal finding caused by the semilunar valves closing at slightly different times. 2)An unusual finding and the physician must be.
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11)A nurse listening to heart sounds a 19-year-old client. The
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21)A nurse assessing an infant and notes a bulging area

21)A nurse is assessing an infant and notes a bulging area in the umbilicus.  What condition would the nurse suspect? 1)Infection 2)Umbilical hernia 3)Ventral hernia 4)Hiatal hernias 22)A nurse is assessing a client’s abdomen and notes loud, high-pitched, rushing, bowel sounds with auscultation.  How should the nurse document these bowel sounds? 1)Hyperactive 2)Bruits 3)Boborygmi 4)Normal 23)A nurse is caring for.
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21)A nurse assessing an infant and notes a bulging area
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11)A nurse assessing an infant and needs to document normal

11)A nurse is assessing an infant and needs to document normal assessment findings of the fontanels.  What is the appropriate documentation? 1)Fontanels diamond shaped 2)Moulding of head noted around fontanels 3)Anterior and posterior fontanels level with the skull 4)Fontanels sunken 12)A new immigrant from India presents with a history of goitre. During the assessment the.
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11)A nurse assessing an infant and needs to document normal
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21)A client, 45 years old, with emphysema being assessed by

21)A client, 45 years old, with emphysema is being assessed by the nurse.  What physical finding would the nurse expect to find in this client? 1)Pectus excavatum 2)Barrel chest 3)Scoliosis 4)Pigeon chest 22)The nurse is examining a client who is diagnosed with a fracture of a floating rib. Which rib is fractured? 1)9 2)5 3)1 4)12 23) During auscultation where.
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21)A client, 45 years old, with emphysema being assessed by
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)What is the correct pattern for auscultating abdominal vascular sounds? 1)Begin in the right lower quadrant and then move to the other quadrants 2)Start midline below the xiphoid process and then side to side 3)The starting point is not.
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11)A nurse interviewing an elderly client and notes several soft,

11)A nurse is interviewing an elderly client and notes several soft, yellow plaques on the eyelids at the inner canthus.  What term would be used to document this finding? 1)Xanthelasma 2)Pterygium 3)Presbyopia 4)Pingueculae 12)A client, 68 years old, tells a nurse that he is experiencing erectile dysfunction since starting on a new medication. The nurse.
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11)A nurse interviewing an elderly client and notes several soft,
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse is performing an assessment on a newborn and notes a thin, milky discharge from the infant’s nipple.  What should the nurse document? 1)Common finding in newborns 2)Highly irregular finding 3)Congenital anomaly 4)Specimen sent for culture 2)A female client is.
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MULTIPLE CHOICE.  Choose the one alternative that best completes the
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse has completed testicular self-examination teaching for a male client.  Which statement if made by the client would indicate the need for further instruction? 1)“I should feel hardened areas where the testicles and epididymis are located.” 2)“I.
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21)A nurse performing an assessment of the head and neck. 

21)A nurse is performing an assessment of the head and neck.  What assessment techniques would the nurse include in the examination? 1)Inspection, palpation, auscultation 2)Palpation, auscultation, percussion 3)Inspection and auscultation 4)Percussion and palpation 22) What muscles form the posterior triangle of the neck? 1)Mandible, midline of the neck, and sternocleidomastoid 2)Clavicle, midline of the neck, and trapezius 3)Manubrium,.
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21)A nurse performing an assessment of the head and neck. 
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11)A nurse examines a client and notes the cervix soft

11)A nurse examines a client and notes the cervix is soft in texture and nontender during the pelvic examination.  What term would the nurse use to document this finding? 1)Chadwick’s sign 2)Piskacek’s sign 3)Hegar’s sign 4)Goodell’s sign 12)A nurse is assessing the fundal height of a pregnant client and notes the fundus is halfway between.
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11)A nurse examines a client and notes the cervix soft
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11)Mrs. Dunlop, 40 years old, being interviewed by the nurse

11)Mrs. Dunlop, 40 years old, is being interviewed by the nurse about breast cancer risks.  Which comment would indicate Mrs. Dunlop understands the risks associated with breast cancer? 1)“My family history is negative so I do not need to worry.” 2)“I will have a clinical breast examination every three years.” 3)“I know my.
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11)Mrs. Dunlop, 40 years old, being interviewed by the nurse
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11)A nurse performing an otoscopic examination of a three-year-old child. 

11)A nurse is performing an otoscopic examination of a three-year-old child.  What technique would the nurse use while inserting the otoscope? 1)Pull the auricle down and back 2)Pull the tragus down and back 3)Pull the auricle up and back 4)Pull the tragus up and back 12) A nurse is performing an otoscopic examination in a.
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11)A nurse performing an otoscopic examination of a three-year-old child. 
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11)A nurse examining the external genitalia of a female client

11)A nurse is examining the external genitalia of a female client and notes small vesicular lesions that are painful.  What conclusion should the nurse make from these findings? 1)Genital warts 2)Herpes infection 3)Bartholin’s abscess 4)Contact dermatitis 12)A nurse is examining the external genitalia of a female client and notes a nontender papule.  The nurse would.
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11)A nurse examining the external genitalia of a female client
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21)A nurse assessing cranial nerve XI (accessory).  What instructions should

21)A nurse is assessing cranial nerve XI (accessory).  What instructions should the nurse provide 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.
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21)A nurse assessing cranial nerve XI (accessory).  What instructions should
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21)A client tells the nurse of pain in the right

21)A client tells the nurse 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.  What conclusion can the nurse make from these findings? 1)   Bunion 2)Synovitis 3)Hammertoe 4)Gout 22)What type of joint is the knee? 1)Saddle 2)Hinge 3)Pivot 4)Plane 23)Mr. Grassie tells the nurse.
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21)A client tells the nurse of pain in the right
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse is preparing to examine a 13-year-old client brought in by the mother.  The child appears uncomfortable throughout the interview and the mother intermittently answers questions directed at the child.  What should the nurse do? 1)Ask.
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)What is the correct landmark for locating the point of maximal impulse? 1)Second intercostal space, right sternal border 2)Second intercostal space, left sternal border 3)Third intercostal space, left sternal border 4)Fifth intercostal space, midclavicular line 2)A nurse is conducting a cardiac.
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21)  What the purpose of the tragus? 1)Equalized ear pressure 2)Hold receptors

21)  What is the purpose of the tragus? 1)Equalized ear pressure 2)Hold receptors necessary for hearing 3)Protects the anterior meatus of the auditory canal 4)Attaches the tongue to the floor of the mouth 22)  What is the normal finding for a Rinne Test? 1) Equal sound to both ears 2)Maintain position without swaying 3)Sound heard twice as long.
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21)  What the purpose of the tragus? 1)Equalized ear pressure 2)Hold receptors
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21)A nurse teaching the student nurse about heart sounds when

21)A nurse is teaching the student nurse about heart sounds when the student asks what causes the S1 heart sound.  What is the correct response? 1)“It results from closure of the semilunar valves.” 2)“You hear it when there is ejection of blood from the atria.” 3)“It results from the closure of the atrioventricular.
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21)A nurse teaching the student nurse about heart sounds when
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse will be performing a distance vision test on a client. What equipment should be used for this examination? 1)Ophthalmoscope 2)Snellen chart 3)Rosenbaum chart 4)Pen light 2)During an interview with the nurse a 24 –year-old client reports difficulty with near.
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21)A nurse assessing a client’s visual fields by confrontation. What

21)A nurse is assessing a client’s visual fields by confrontation. What instructions should the nurse provide the client in preparation for this eye test? 1)"Follow the pen light with your eyes only." 2)"Keep both eyes uncovered and focus on the examiners forehead." 3)"Cover one eye with the card." 4)"Say no when you can no.
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21)A nurse assessing a client’s visual fields by confrontation. What
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21)The arm blood pressures of a 4-year-old client 108/65 left

21)The arm blood pressures of a 4-year-old client are 108/65 left and 110/66 right.  The nurse obtains a thigh pressure of 88/48.   What condition would the nurse would suspect? 1)Normal in young children 2)Coarctation of the aorta 3)Atherosclerosis 4)Peripheral vascular disease 22)A client is examined for concerns of bluish discolouration of the hands and fingers. .
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21)The arm blood pressures of a 4-year-old client 108/65 left
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31)   Maddox, 1 week old, assessed by the nurse. What

31)   Maddox, 1 week old, is assessed by the nurse. What is a normal finding in Maddox? 1)  Forefeet are turned outward 2)  Positive Ortolani’s sign 3)  Arches in both feet 4)  Tibial torsion 32)  What landmark is used to assess the hips? 1)  Lesser trochanter 2)  Anterior inferior iliac spine 3)  Symphysis pubis 4)  Ischial tuberosity SHORT ANSWER.  Write.
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31)   Maddox, 1 week old, assessed by the nurse. What
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11)A nurse percussing the posterior thorax of a client with

11)A nurse is percussing the posterior thorax of a client with emphysema. What sound does the nurse anticipate hearing? 1)Resonance 2)Hyperresonance 3)Fremitus 4)Bronchial 12) During auscultation where are vesicular breath sounds heard on the thorax? 1)Over the lung fields 2)Over the trachea 3)Next to the trachea 4)Between the scapula 13)Jordan, 3 years old, has an obstructed airway. The nurse hears.
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11)A nurse percussing the posterior thorax of a client with
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MULTIPLE CHOICE.  Choose the one alternative that best completes the

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question. 1)A nurse is preforming auscultation on a client who has significant atelectasis in the right lower lung field. What would the nurse anticipate hearing in this area of the lung? 1)Sonorous wheeze 2)Increased whisper pectoriloquy 3)Decreased breath sounds 4)Lack of tactile.
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11)A nurse caring for a client admitted with an infection

11)A nurse is caring for a client admitted with an infection of the ureters. What other structure could be involved with this infection? 1)Capsule 2)Cortex 3)Medulla 4)Pelvis 12)A client has been diagnosed with azotemia. What assessment finding will the nurse anticipate being present? 1)Hematuria 2)Confusion 3)Increase urine output 4)Decreased sensation of thirst 13)A nurse is assessing an infant and notices.
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11)A nurse caring for a client admitted with an infection
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