Health Assessment 1-50 Questionnaire
AH1. A new graduate nurse is working in a busy emergency department of a
hospital, situated in a culturally diverse area of the city. In striving to be culturally
sensitive, what should the nurse do?
[Link] to learn about the attitudes toward health care and traditions of the different
cultures in that area.
[Link] and attend to the total context of the client's situation, using
knowledge, attitudes, and skills.
[Link] the underlying background knowledge that will provide these clients
with the best possible health care.
[Link] strive to be culturally competent.
* Cultural sensitivity implies that nurses possess some basic knowledge of and
constructive attitudes toward the health traditions observed among the
diverse cultural groups found in the setting in which they are practicing.
AH2. A client who is from a different culture than the nurse has not been able to
achieve this goal: Client will select low-fat foods from a list by the end of the
month. What should the nurse do?
[Link] whether the client's belief system has been an influencing factor.
[Link] the time frame and give the client a longer period to achieve the goal.
[Link] sure that the client understands the importance of the goal.
[Link] a different goal.
* If the outcomes are not achieved for a client from a different culture, the
nurse should be especially careful to consider whether the clients belief system
has been adequately included as an influencing factor
AH3. The nurse manager is concerned that a staff nurse provides client care with a
cultural prejudice. Which situation did the manager observe to come to this
conclusion?
[Link] an assumption that all members of each culture are alike
[Link] that all culture members will have the same beliefs
[Link] previous negative information and experiences into this situation
[Link] general knowledge from literature and applying it to the situation
* Prejudice is a negative belief or preference that is generalized about a group,
which leads to prejudgment. Prejudice occurs when the person making the
judgment generalizes an experience of one individual from a culture to all
members of that group.
AH4. A new graduate nurse is moving from a small rural college town to a
metropolitan area to begin work in a county hospital. The nurse has had limited
prior experience with the various cultural groups that are served by the hospital.
What might be this nurse’s greatest challenge?
[Link]
[Link]
[Link]
[Link]
*Assimilation is the process by which an individual develops a new cultural
identity. Assimilation means becoming like the members of the dominant
culture. Because this is a conscious effort, it is not always possible, and the
process may cause severe stress and anxiety.
AH5. A client has requested that she have a special item present in her room and
explains that it gives her a feeling of comfort and a sense of organization. On
which psychosocial component is this client focusing?
[Link]
[Link]
[Link]
[Link]
*Religion may be defined by a system of beliefs, practices, and ethical values
about divine or superhuman power and is closely related to ethnicity. Religion
gives a person a frame of reference and a perspective with which to organize
information.
AH6. A client makes the following statement: "I must be paying for all the wrongs
I did in my life, to have such a diagnosis as this." The nurse suspects that this client
views health from which type of belief?
[Link]-religious belief
[Link] health belief
[Link] health belief
[Link] medicine
*In the magico-religious health belief view, health and illness are controlled
by supernatural forces. The client may believe that illness is the result of being
bad or opposing Gods will.
AH7. A Chinese client is hospitalized with a fever of unknown origin and follows
a very traditional, cultural view of illness. Which food should the nurse offer the
client?
[Link] tea
[Link] soup
[Link] meat
[Link] liquids
*The concept of yin and yang in the Chinese culture is an example of a holistic
health belief. A Chinese client who has a yang illness, or a hot illness, may
prefer a yin or cold treatment. In this case, the fever would be considered a
hot illness and the client may prefer the opposite or yin treatment.
AH8. A female client is being discharged after a lengthy hospitalization. The
family is from a male-dominated culture. Before discharge instructions are given,
which action should the nurse take?
[Link] sure instructions are understood by the client.
[Link] for teaching when the spouse is available.
[Link] sure that the physician gives the instructions.
[Link] the client when the best time for teaching would be.
*The nurse needs to identify who has the authority to make decisions in a
clients family. If the decision maker is someone other than the client, as in this
situation, the nurse needs to include that person in health care discussions. In
this situation, we do not know if the nurse is male or female, so the best
answer given with the information that is known is to arrange for teaching
when the spouse is available.
AH9. A newly immigrated client is constantly attended to by family members.
This has presented a problem to the nursing staff and the delivery of nursing care.
In order to address this issue in a culturally sensitive manner, the nurse should take
which action?
[Link] to the client that he has to limit visitors.
[Link] the benefits of family participation in the client's care.
[Link] the family members as to how they see their interaction with the client.
[Link] the physician limit the number of visitors the client can have.
*Cultural family values may dictate the extent of the familys involvement in
the hospitalized clients care. In some cultures, the entire community may want
to visit and participate in the clients care. The nurse should evaluate the
positive benefits of family participation in the clients care and modify visiting
policies as appropriate.
AH10. The nurse is planning to conduct a physical assessment with a client from a
different culture. What is the best way for the nurse to show cultural sensitivity
when addressing the personal questions required of the nursing history?
[Link] the assessment into shorter intervals and discuss general topics first.
[Link] explain the reason for asking many questions before beginning the
assessment.
[Link] a time when the family is present and can help with the admission
assessment questions.
[Link] until the nurse–client relationship has been established.
*Clients may be offended when the nurse immediately asks personal
questions. In some cultures, courtesies should be established before business
or personal topics are discussed. Discussing general topics can convey that the
nurse is interested and has time for the client. This enables the nurse to
develop a rapport with the client before progressing to discussion that is more
personal.
AH11. During the admission interview, the culturally diverse client averts her eyes
and refrains from answering questions for long periods of time. The culturally
sensitive nurse should take which action?
[Link] back at a different time, when the client is feeling more communicative.
[Link] another nurse finish the interview, as there is something uncomfortable the
client senses.
[Link] that this may be completely appropriate and take cues accordingly.
[Link] the room and come back after having learned more about this particular
culture.
*Nonverbal communication includes silence, touch, eye movement, facial
expressions, and body posture. Some cultures are quite comfortable with long
periods of silence. Many people value silence and view it as essential to
understanding a person’s needs or use silence to preserve privacy. Before
assigning meaning to nonverbal behaviour, the nurse must consider the
possibility that the behaviour may have a different meaning for the client and
family.
AH12. The nurse needs to determine the apical pulse of a client from a different
culture. In order to show appropriate sensitivity to the client, the nurse should take
which action?
[Link] the procedure, then wait for permission to continue.
[Link] to the client what will occur during the assessment.
[Link] the client to stay quiet because the nurse will be listening to the heart.
[Link] the baseline vital signs, then determine if cardiac auscultation is necessary.
*Cardiac assessment requires that the nurse move into the client’s intimate
space. Before beginning this, the nurse should explain the procedure and then
await permission to continue.
AH13. The nurse is working in a clinic setting and is meeting a new client for the
first time. In order to convey cultural sensitivity, how should the nurse introduce
herself?
A."I'm Jane, and I'll be your nurse today."
B."I'm Dr. Smith's nurse, Jane."
C."I'm Jane Brown, and I'm a nurse here at the clinic."
D."I'm glad to meet you. You can call me Jane."
*Ways for nurses to be culturally sensitive and to convey sensitivity to clients
include introducing themselves by full name, then explaining their role. This
helps establish a relationship and provides an opportunity for clients, others,
and nurses to learn the pronunciation of one anothers names and their roles.
AH14. A home health client participates in cultural health practices that the nurse
feels may be detrimental to his health. In order to remain attentive to cultural
sensitivity and provide appropriate cultural nursing care, the nurse should take
which action?
[Link] the right and wrong of the client's treatment and try to persuade him to
follow the scientific perspective.
[Link] the client's physician explain the care to the client in a firm but gentle
manner.
[Link] the client's practices and understand that for this client, it may be
beneficial to continue with his preferences.
[Link] to negotiate with the client by exploring his views and then provide relevant
scientific information.
*Negotiation acknowledges that the nurse client relationship is reciprocal and
that different views exist of health, illness, and treatment. During the
negotiation process, the clients views are explored and acknowledged, then
relevant scientific information is provided.
AH15. The nurse is caring for an 8-month-old infant. What is the best tool the
nurse should use for evaluating pain in this infant?
[Link] scale
[Link]-Baker FACES
[Link] analog scale
[Link] rating scale
*The FLACC scale or Face, Legs, Activity, Cry, Consolability scale is a
measurement used to assess pain for children between the ages of 2 months
and 7 years or individuals that are unable to communicate their pain. The
scale is scored in a range of 0–10 with 0 representing no pain.
AH16. Which of the following objective assessment data will the nurse obtain
before administering a prescribed opioid medication to a client?
[Link] level as stated by client
[Link] nausea the client may be feeling
[Link] rate
[Link] of skin
*Opioids may depress the respiratory system, so the nurse should assess the
respiratory rate before administering opioids. Options 1 and 2 are subjective
data. Option 4 is not applicable to assess prior to administering an opioid
medication to a client.
AH17. The nurse is to administer acetaminophen (Tylenol) prn to a client for a
headache; however, the client has been vomiting all day. Which route should the
nurse use to administer the medication?
[Link]
[Link]
[Link]
[Link]
*Rationale 1: The rectal route is often used if the client has nausea or
vomiting. The nurse should administer an acetaminophen suppository to the
client.
Rationale 2: This medication is not available as a vaginal suppository.
Rationale 3: The rectal route is often used if the client has nausea or vomiting.
The nurse should administer an
acetaminophen suppository to the client.
Rationale 4: There is not an intravenous form of this medication.
AH18. A client recovering from a left below-the-knee amputation is experiencing
left foot pain. The nurse realizes the client is experiencing which type of pain?
[Link] limb pain
[Link] pain
[Link] pain
[Link]-induced pain
*Rationale 1: Phantom sensations, the feeling that a lost body part is present,
occur in most people after amputation. It is important for the nurse to
remember to explain the reasons for phantom limb pain, as clients may have
difficulty understanding why they have pain when the limb is gone.
Rationale 2: Acute pain is directly related to tissue injury and resolves when
tissue heals.
Rationale 3: Chronic pain persists beyond 3 to 6 months secondary to chronic
disorders or nerve malfunctions
that produce ongoing pain after healing is complete.
Rationale 4: There is no such type of pain.
AH19. The nurse is providing discharge instructions to a client prescribed an
opioid medication. What should the nurse suggest to decrease the risk of
constipation with this medication?
[Link] an antihistamine three times per day.
[Link] 6 to 8 glasses of water per day.
[Link] respiratory rate before taking medication.
[Link] heart rate before taking medication.
*Antihistamines do not prevent constipation.
Rationale 2: Increasing fluid intake can help prevent constipation.
Rationale 3: Assessing respiratory rate will not help prevent constipation.
Rationale 4: Assessing heart rate will not impact the development of
constipation.
AH20. The nurse is admitting a client to the emergency department with
complaints of severe abdominal pain. What is the nurse's first action?
[Link] IV pain medication as ordered.
[Link] an IV line of lactated Ringer's.
[Link] pain using a scale of 1 to 10.
[Link] a Foley catheter to bedside drainage.
*Rationale 1: This would occur after the client was assessed.
Rationale 2: This would occur after the client was assessed.
Rationale 3: Assessment should always occur before implementation.
Rationale 4: This may or may not be appropriate for the client.
AH21. A client is surprised to learn of the diagnosis of a heart attack when there
was no chest pain experienced but only some left shoulder pain. The nurse should
explain that the client experienced which type of pain?
[Link] pain
[Link] pain
[Link] pain
[Link] pain
*Rationale 1: Phantom pain is that which is experienced in a limb after an
amputation.
Rationale 2: Referred pain appears to arise in different areas of the body, as
may occur with cardiac pain.
Rationale 3: Visceral pain originates in an organ.
Rationale 4: Chronic pain is that which is felt for months after the pain
experience should have ended.
AH22. A client rates pain as being 7 on a scale from 0 to 10. What should the
nurse document as this client's pain intensity?
[Link] pain
[Link] pain
[Link] pain
[Link] pain
*Rationale 1: Mild pain is rated as being from 1 to 3 on a 0-to-10 rating scale.
Rationale 2: Moderate pain is rated as being from 4 to 6 on a 0-to-10 rating
scale.
Rationale 3: Severe pain is rated as being from 7 to 10 on a scale of 0 to 10.
Rationale 4: Physiological pain does not describe the intensity of the clients
pain.
AH23. A client is experiencing pain after spraining an ankle. The nurse realizes
that the client is most likely experiencing which type of pain?
[Link] pain
[Link] pain
[Link] pain
[Link] pain
*Rationale 1: Mild is not a type of pain.
Rationale 2: Severe is not a type of pain.
Rationale 3: Somatic pain originates in the skin, muscles, bone, or connective
tissue. The sharp sensation of a paper cut or aching of a sprained ankle are
common examples of somatic pain.
Rationale 4: Visceral pain is that which originates within an organ.
AH24. The client scheduled to undergo minor surgery states, "The physician will
not give me pain medication after surgery because my surgery is only minor."
What is the best response by the nurse?
A."You can experience pain after minor surgery, so you can have pain
medication."
B."You are correct. The physician will not order any pain medication."
C."You are correct. I will need to teach you nonpharmacologic pain relief
measures."
D." You can only have about half the dose because your surgery is minor."
*Rationale 1: Clients can experience intense pain after minor surgery, so pain
medication may be ordered.
Rationale 2: This is not true. The client can have pain after minor surgery and
can receive pain medication.
Rationale 3: Nonpharmacologic pain relief measures may not be enough for
the pain after surgery.
Rationale 4: The nurse has no way of knowing the dose the physician will
prescribe for the client.
AH25. The nurse is caring for a postpartum client receiving pain medication
through an epidural catheter. Which assessment finding should the nurse report
immediately to the physician?
[Link] rate: 80
[Link] rate: 8
[Link] pressure: 120/80
[Link] rating of 4 on scale of 1 to 10
*Rationale 1: This is a normal pulse rate.
Rationale 2: A respiratory rate below 8 should be reported immediately.
Rationale 3: This is a blood pressure that is within normal limits.
Rationale 4: The nurse does not need to report the client’s pain rating to the
physician.
AH26. A client states that a cramping pain started 2 hours ago and is not
accompanied by any nausea or vomiting. Which type of pain is this client most
likely experiencing?
[Link] pain
[Link] pain
[Link] pain
[Link] pain
*Rationale 1: Chronic pain, also known as persistent pain, is prolonged,
usually recurring or lasting 3 months or longer, and interferes with
functioning.
Rationale 2: Phantom pain is the feeling that a lost body part is present. It
occurs in most people after amputation.
Rationale 3: Visceral pain tends to be characterized by cramping, throbbing,
pressing, or aching qualities. Often visceral pain is associated with feeling
sick.
Rationale 4: Acute pain is pain that is directly related to tissue injury and
resolves when tissue heals.
AH27. The nurse is preparing to conduct a pain assessment. The following should
be included in this assessment except:
[Link]
[Link]
[Link]
[Link]
[Link]
*Rationale 1: Pain may be described in terms of duration.
Rationale 2: Pain may be described in terms of location.
Rationale 3: Pain may be described in terms of intensity.
Rationale 4: Pain may be described in terms of etiology.
Rationale 5: Pain is not described in terms of neurology.
AH28. A client is complaining of having the same type of pain that he experienced
prior to being diagnosed with cancer. The nurse realizes that which process will
influence this client’s perception of pain?
[Link]
[Link]
[Link]
[Link]
*Rationale 1: Transmission is a process by which the pain signals are
transmitted to the brain.
Rationale 2: Modulation is the process where signals are sent back down the
spinal tracts in response to the pain.
Rationale 3: Perception is when the client becomes conscious of the pain. Pain
perception is the sum of complex activities in the central nervous system that
can shape the character and intensity of pain perceived and ascribes meaning
to the pain. The psychosocial context of the situation and the meaning of the
pain based on past experiences and future hopes and dreams help to shape the
behavioural response that follows.
Rationale 4: Transduction is a process whereby chemicals are released in
response to noxious stimuli.
AH29. A client tells the nurse that an ice pack works well to reduce the intensity of
back pain. The nurse realizes that the client is implementing
A.a placebo.
[Link].
[Link] imagery.
[Link] gate control theory of pain.
*Rationale 1: The application of ice is not a placebo.
Rationale 2: The application of ice is not a distraction.
Rationale 3: The application of ice is not a use of guided imagery.
Rationale 4: In the gate control theory, signals of noxious stimuli are carried
to the dorsal horn, where they are modified according to the balance of the
substantia gelatinosa. By using ice, the substantia gelatinosa is calmed,
reducing the pain.
AH30. A client with pain has had previous episodes of uncontrolled pain in the
past and is worried about the current pain pattern. Which diagnosis would be
appropriate for the nurse to include for this client?
[Link]
[Link] Coping
[Link] Knowledge
[Link]
*Rationale 1: The diagnosis of Anxiety would be appropriate for the client, as
the client has past experiences of poor pain control and is anticipating pain.
Rationale 2: The diagnosis of Ineffective Coping would be applicable if the
client were experiencing prolonged pain because of ineffective pain
management.
Rationale 3: The diagnosis of Deficient Knowledge would be applicable if the
client had a lack of exposure to information regarding pain management.
Rationale 4: The diagnosis of Hopelessness would be appropriate if the client
were experiencing continuous pain.
AH31. The nurse is preparing to perform a health assessment of the abdomen. In
which order should the nurse perform the assessment?
[Link], percuss, palpate, inspect
[Link], auscultate, palpate, percuss
[Link], auscultate, percuss, palpate
[Link], percuss, auscultate, inspect
*Inspection should occur first. Palpation should always be performed last
when performing an abdominal health assessment. Auscultation is done
before palpation and percussion because palpation and percussion cause
movement or stimulation of the bowel, which can increase bowel motility and
thus heighten bowel sounds, creating false results.
AH32. The nurse is performing a health assessment and notes a yellow tinge to the
sclera of the eye. The nurse should document this as being
[Link].
[Link].
[Link].
[Link].
*Jaundice is a yellow tinge that is abnormal and is often noticed in the sclera
of the eye.
AH33. While performing an assessment of the integument system, the nurse notes
the client's eyeballs are protruding and the upper eyelids are elevated. What term
should the nurse use to document this finding?
[Link]
[Link]
[Link]
[Link]
*Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with
elevation of the upper eyelids, resulting in a startled or staring expression.
AH34. The nurse is preparing for morning rounds. What should the nurse avoid
delegating to unlicensed assistive personnel?
[Link] signs
[Link] of water pitchers
[Link] and face assessment
[Link] of surgical clients
*Rationale 1: Vital signs can appropriately be delegated to unlicensed
assistive personnel.
Rationale 2: Filling of water pitchers can be appropriately delegated to
unlicensed assistive personnel.
Rationale 3: Assessment of the skull and face may not be delegated to
unlicensed assistive personnel.
Rationale 4: Ambulation of surgical clients can be appropriately delegated to
unlicensed assistive personnel.
AH35. The nurse is performing a lung assessment on a client with suspected
pneumonia. Which finding should the nurse report to the physician immediately?
[Link] symmetrical
[Link] sounds equal bilaterally
[Link] chest expansion
[Link] symmetric vocal fremitus
*Rationale 1: Symmetrical chest expansion is an expected finding.
Rationale 2: Bilaterally equal breath sounds is a normal assessment finding.
Rationale 3: Chest expansion should be symmetrical.
Rationale 4: Bilaterally equal vocal fremitus is a normal assessment finding.
AH36. While performing a health assessment, in which position should the nurse
place the client for inspection of the jugular veins?
A.90-degree angle
B.30- to 45-degree angle
C.15-degree angle
D.60-degree angle
*Rationale 1: This is not the correct angle.
Rationale 2: The nurse should place the client in the semi-Fowlers position
(30- to 45-degree angle) while inspecting the jugular veins for distention.
Rationale 3: This is not the correct angle.
Rationale 4: This is not the correct angle.
AH37. The nurse is assessing peripheral pulses on a client with suspected
peripheral vascular disease. Which finding should the nurse report to the physician
immediately?
[Link] equal bilaterally
[Link] pulsations
[Link] pulses
[Link] present bilaterally
*Rationale 1: Bilateral equal pulses are a normal assessment finding.
Rationale 2: A full pulsation is a normal assessment finding.
Rationale 3: Thready, weak, or decreased pulses are abnormal and should be
reported to the physician.
Rationale 4: Bilaterally present pulses are a normal assessment finding.
AH38. During the assessment of a client’s breasts, the nurse finds both breasts
rounded, slightly unequal in size, skin smooth and intact, and nipples without
discharge. What should the nurse do next?
[Link] the charge nurse.
[Link] the physician.
[Link] the findings in the nurse's notes as normal.
[Link] the findings in the nurse's notes as abnormal.
*Rationale 1: The findings are all normal, so the nurse does not need to notify
the charge nurse.
Rationale 2: The findings are all normal, so the nurse does not need to notify
the physician.
Rationale 3: The findings are all normal, so the nurse would document the
assessment in the nurses notes as normal.
Rationale 4: The findings are all normal, so the nurse would not document the
findings as abnormal.
AH39 The nurse is preparing a client for an abdominal examination. What should
the nurse done before beginning the examination?
[Link] the client to urinate.
[Link] the client to drink 8 ounces of water.
[Link] vital signs.
[Link] heart rate.
*Rationale 1: The nurse should ask the client to urinate because an empty
bladder makes the assessment more comfortable.
Rationale 2: Drinking fluids will cause the clients bladder to fill and cause
discomfort.
Rationale 3: The clients vital signs do not need to be assessed prior to an
abdominal examination.
Rationale 4: The client does not need to have an apical heart rate assessed
prior to having an abdominal assessment.
AH40. The nurse is performing a musculoskeletal assessment on a client admitted
with a possible stroke. When testing for muscle grip strength, the nurse should ask
the client to perform which action?
[Link] the nurse's index and middle fingers while the nurse tries to pull the
fingers out.
[Link] an arm up and resist while the nurse tries to push it down.
[Link] each arm and then try to extend it against the nurse's attempt to keep the
arm in flexion.
[Link] the shoulders against the resistance of the nurse's hands.
*Rationale 1: This is the technique to assess muscle grip strength.
Rationale 2: This is a technique to assess muscle strength but not grip
strength.
Rationale 3: This is a technique to assess muscle strength but not grip
strength.
Rationale 4: This is a technique to assess muscle strength but not grip
strength.
AH41. The nurse is preparing to conduct a mental status assessment. What should
the nurse include in this assessment?
[Link] and affective functions
[Link] and effective functions
[Link] and memory functions
[Link] and knowledge functions
*Rationale 1: Cognitive (intellectual) and affective (emotional) functions are
assessed.
Rationale 2: There are no effective functions.
Rationale 3: The mental status assessment does not include an assessment of
memory.
Rationale 4: A mental status assessment does not include a knowledge
assessment.
AH42. The nurse is caring for a client following a cerebrovascular accident
(stroke). The client is able to comprehend what is being said to him; however, he is
unable to respond by speech or writing. What type of aphasia should the nurse
realize this patient is demonstrating?
[Link] aphasia
[Link] aphasia
[Link] aphasia
[Link] aphasia
*Rationale 1: Clients with auditory aphasia have lost the ability to understand
the symbolic content associated with sounds.
Rationale 2: This is the same as auditory aphasia.
Rationale 3: Sensory or receptive aphasia is the loss of the ability to
comprehend written or spoken words.
Rationale 4: Motor or expressive aphasia involves loss of the power to express
oneself by writing, making signs, or speaking. Clients may find that even
though they can recall words, they have lost the ability to combine speech
sounds into words.
AH43. The nurse is preparing to assess a client's reflexes. What equipment should
the nurse gather before entering the room?
[Link] gloves
[Link] gloves
[Link] hammer
[Link]
*Rationale 1: Sterile gloves are not needed to test reflexes.
Rationale 2: Clean gloves are not needed to test reflexes.
Rationale 3: A percussion hammer is used to test reflexes.
Rationale 4: A penlight is not used to test reflexes.
AH44. The nurse is assisting the physician who is preparing to test a sexually
active female client for cervical cancer. What should the nurse expect the health
care provider to perform?
[Link] test
[Link] exam
[Link] exam
[Link] exam
*Rationale 1: For sexually active adolescent and adult women, a Papanicolaou
test (Pap test) is used to detect cancer of the cervix.
Rationale 2: A breast examination is not done specifically for sexually active
clients.
Rationale 3: A rectal exam is not done specifically for sexually active clients.
Rationale 4: An abdominal exam is not done specifically for sexually active
clients.
AH45. The nurse is preparing the morning assignments. Which assessment could
the nurse delegate to unlicensed assistive personnel?
[Link] assessment
[Link] assessment
[Link] signs assessment
[Link] genital assessment
*Rationale 1: The UAP cannot perform a neurological assessment.
Rationale 2: The UAP cannot perform a musculoskeletal assessment.
Rationale 3: The nursing assistant can only assess vital signs.
Rationale 4: The UAP cannot perform a female genital assessment.
AH46. The nurse is preparing to administer a cardiotonic drug to a client. Which
assessment should the nurse perform before administering the medication?
[Link] rate
[Link] pulse
[Link] pulse
[Link] blanch test
*Rationale 1: The nurse does not need to assess the clients respiratory rate
before providing the medication.
Rationale 2: The apical pulse should be assessed before administering any
cardiotonic medication.
Rationale 3: The clients popliteal pulse does not need to be assessed prior to
receiving this medication.
Rationale 4: The clients capillary blanching does not need to be assessed prior
to receiving this medication.
AH47. The nurse is preparing to complete a physical examination on a client. The
following are the purpose for this examination except:
[Link] baseline data.
[Link] data to help determine nursing diagnoses.
[Link] areas for disease prevention.
[Link] the client’s employment status.
*Rationale 1: One purpose of the physical examination is to obtain baseline
data.
Rationale 2: One purpose of the physical examination is to obtain data to help
determine nursing diagnoses.
Rationale 3: One purpose of the physical examination is to identify areas for
disease prevention.
Rationale 4: The physical examination is not done to identify the clients
employment status.
Rationale 5: The physical examination is not done to obtain data about a
clients leisure activities.
AH48. A client has been receiving a new medication to address specific symptoms.
The nurse will perform a physical examination to determine,
[Link] physiological impact of the prescribed medication.
[Link] data.
[Link] to support nursing diagnoses.
[Link] for health promotion.
*Rationale 1: The nurse will perform a physical examination on a client to
determine the progress of the client’s health problem.
Rationale 2: The nurse will perform a physical examination on a client to
determine the physiological impact of the prescribed medication.
Rationale 3: The nurse will not be performing a physical examination to
collect baseline data.
Rationale 4: The nurse will not be performing a physical examination to
support nursing diagnoses.
Rationale 5: The nurse will not be performing a physical examination to
identify areas for health promotion
AH49. The nurse is utilizing the technique of inspection during a physical
examination with a client. When using this technique, the nurse will take which
actions? Select all that apply.
[Link] observe a body area.
[Link] information through the sense of smell.
[Link] information through the sense of hearing.
[Link] the body through the use of touch.
[Link] the body to elicit a sound from a body part.
*Rationale 1: When using inspection, the nurse will visually observe a body
area.
Rationale 2: In addition to visual observation, olfactory cues are noted.
Rationale 3: In addition to visual observation, auditory cues are noted.
Rationale 4: Examining the body through use of touch describes palpation.
Rationale 5: Striking the body to elicit a sound from a body part describes
percussion.
AH50. The nurse is planning to perform indirect percussion on an area of a client’s
body during a physical examination. Which actions should the nurse take to use
this assessment technique? Select all that apply.
[Link] the middle finger of the nondominant hand on the client’s skin.
[Link] the tip of the flexed middle finger of the other hand to strike the middle
finger of the nondominant hand.
[Link] a striking motion by moving the wrist.
[Link] short, rapid, firm blows.
[Link] a stethoscope to transmit sounds to the ears.
*Rationale 1: Placing the middle finger of the nondominant hand on the
clients skin is the first step when performing indirect percussion.
Rationale 2: Using the tip of the flexed middle finger of the other hand to
strike the middle finger of the nondominant hand is the second step when
performing indirect percussion.
Rationale 3: The nurse should perform a striking motion by moving the wrist.
Rationale 4: The nurse should perform short, rapid, firm blows.
Rationale 5: Using a stethoscope to transmit sounds to the ears is done during
auscultation, not indirect percussion.
