A nurse is beginning a head to toe assessment for a client. In general, what order should the tasks be performed for each body system?

A nurse is precepting a nursing student. Which action by the nursing student requires intervention by the nurse?

A client who is in the hospital to deliver a baby does not speak English. The nurse attempts to call for an interpreter but the client refuses to use one. Which information would the nurse document in this situation? Select all that apply.

A client in the hospital has a Hispanic background and does not speak English. The nurse tries to call an interpreter but no one is available, so the nurse opts to use the client’s adolescent son as an interpreter. Which of the following must the nurse consider when using a family member as a language interpreter? Select all that apply.

A 29-year-old pregnant client arrives at the hospital in active labor. The client is deaf and her husband is with her. Which intervention from the nurse expresses her ability to communicate with this client?

In helping a blind client have a sense of safety and security, the nurse should do which of the following? Select all that apply.

A diabetic client in the care clinic is complaining of feeling anxious. The nurse notes that the client is sweaty, has tremors, and is tachycardic. Which intervention would the nurse most likely perform in response?

A nurse is caring for a client who needs an MRI for a back injury. The client is deaf. The nurse has provided written information for the client but needs to find out if there are any questions. In which way would the nurse most likely act as the client’s advocate?

A nurse is caring for an Asian client who is being seen for a bleeding disorder. Whenever the nurse enters the room, the client averts her eyes and avoids eye contact. She answers the nurse’s questions but refuses to look at the nurse. Which of the following is the client most likely demonstrating?

A nurse is caring for a postpartum client who is Vietnamese and speaks little English. Because of complications with delivery, the mother experienced a larger amount of blood loss, and the provider has ordered an increase in IV fluids as well as encouraging oral intake of fluids. The nurse brings the mother a pitcher of ice water and the client becomes visibly upset. Which response from the nurse is most appropriate?

After receiving a terminal diagnosis of congestive heart failure, a client is hostile to family members and hospital staff. The family is upset by this and asks why the client is so hostile. Which of the following responses by the nurse is most appropriate?

The nurse is caring for a client who is blind. The nurse should perform which of the following actions to best communicate with this client? Select all that apply.

A 66-year-old client is being seen for a skin assessment. The nurse notes several brown spots on the client’s face that the client refers to as liver spots. What is the technical term for this condition?

A nurse is palpating a client’s abdomen to check for an abdominal aortic aneurysm during a physical assessment. Which part of the hand would the nurse most likely use to palpate for this finding?

A nurse is performing an abdominal assessment on a client who complains of abdominal pain. Which of the following would be subjective information about the client? Select all that apply.

A nurse is assessing an adult client in the emergency department who has a respiratory rate of 32/minute. Which of the following are potential causes of tachypnea? Select all that apply.

Which best describes the order in which the nurse should assess a client’s abdomen?

A nurse is caring for a client who had surgery two days ago. The client has a peripheral IV in place. Which of the following should the nurse include as part of a standard assessment of the adequacy of this client’s IV? Select all that apply.

A nurse is caring for a 15-year-old client who is recovering from an appendectomy. The nurse is assessing the client’s level of pain. Which question from the nurse would be most appropriate for determining the intensity of pain the client is experiencing?

A client is brought to the recovery room after hip surgery. The nurse performs an initial assessment of the client’s respiratory and hemodynamic status. Which of the following signs or symptoms would most likely indicate a complication during this period?

A nurse is assessing a client’s nutritional status. In addition to checking the client’s weight, which of the following assessments would the nurse include to check for malnutrition?

A community health nurse is performing a skin assessment on a client. The nurse discovers the lesion depicted in this image on the client’s back. It is 9 mm wide. What should the nurse do next?

A nurse is working with a client who has been infected with methicillin-resistant staphylococcus aureus (MRSA). The nurse needs to check the client’s vital signs using a blood pressure cuff that is normally kept in the central supply area of the unit. Which action should the nurse perform that is most appropriate to prevent spread of this infection?

A client is being assessed and has a temperature of 104.2F. Which of the following actions should the nurse take first?

The nurse is attempting to count the heart rate on an EKG graph and notices the client has an irregular rhythm. The nurse knows that which of the following is the best method to obtain an accurate heart rate?

A nurse is assessing a client in the primary care clinic and notes an elevated pulse rate. Which of the following factors would cause a person to have an increased heart rate? Select all that apply.

A client came in with a temperature of 105F. On assessment the nurse notes the client to be confused. The client is hot to the touch but not sweaty and has a weak pulse. The nurse should implement which of the following precaution types for this client?

After having surgery for a shoulder replacement under general anesthesia, the client became excessively hot with a temperature of 104.5F. The nurse would be concerned about which of the following?

The nurse is caring for a client who is having shortness of breath upon exertion, cough, and dizzy spells. The client denies chest pain, loss of consciousness, and fever. Vital signs are stable with the exception of the oxygen saturation, which is 86% according to the pulse oximeter. For which of the following potential scenarios will the nurse monitor? Select all that apply.

The nurse is caring for a client who arrives at the emergency department after falling down multiple times. Upon initial assessment, the client states, “I am so dizzy I can’t stay standing up.” What is the nurse’s first priority?

The nurse just received reports on the following four clients Which client should the nurse see first? 1) A 54-year-old with a blood pressure of 140/90 mmHg 2) An 89-year-old with a heart rate of 110 3) A 40-year-old with a respiration rate of 30 breaths per minute 4) A 91-year-old who needs to use the bathroom.

A nurses receives report on several clients. The nurse knows to be most concerned about hyperthermia with which of the following client temperatures?

A nurse is providing newborn care education to first time parents. The parents ask how to take the baby’s temperature. Which is the most recommended and most accurate route for taking an infant’s temperature that can be suggested to the parents?

A nurse is counseling a client who has hypertension and type 2 diabetes. During the initial assessment, the nurse notes that the client has a blood pressure of 148/92 mmHg, a BMI of 28, and a blood glucose level of 161 mg/dL. Which of the following information about health and wellness would be most beneficial for the nurse to teach this client?

The nurse is performing an initial assessment on a new client in the clinic. Which of the following elements would be included as part of the general survey? Select all that apply.

In which situation would it be most appropriate to perform a comprehensive health history assessment on a client?

A nurse is performing an initial assessment on a client who is being admitted to the hospital for exacerbation of heart failure. During the client interview, the nurse wants to assess the client’s background and health history. Which of the following are examples of leading questions that the nurse should avoid? Select all that apply.

During an initial assessment of a client with coronary artery disease, the nurse wants to assess the client’s dietary intake to determine if diet is contributing to his health condition. Which question would most likely give the nurse an idea of the client’s everyday diet?

Which of the following findings would the nurse expect to find during a skin assessment for a client with vasculitis?

A client just found out they have seborrheic keratosis. The client asks, “How much longer do I have to live?” Which of the following is the best response by the nurse?

The nurse is charting a skin assessment on the newly admitted client. The client has cuts on the wrists from attempted suicide. The nurse should chart this using what terminology?

The nurse is charting a skin assessment on the newly admitted client. The client has a flat and non-palpable discoloration on their leg that is less than one cm in size. The nurse should chart this using what terminology?

A nurse is providing skin care to a client who has been incontinent in the bed. The nurse knows that incontinence causes skin breakdown through maceration of the skin. Which describes how maceration occurs through incontinence? Select all that apply.

A nurse who works in a long-term care facility has noted that one of her clients is frequently incontinent of urine and stool. The client also has mobility issues and the nurse is concerned about skin breakdown in this client. Which actions should the nurse perform to prevent skin breakdown? Select all that apply.

There are 4 clients in the emergency room that have some sort of laceration or cut. Which laceration should the nurse see first?

A 79-year-old client has an appointment at a dermatology office for a skin assessment and removal of a suspicious mole. The nurse assesses the client’s skin texture and turgor. Which types of skin issues would the nurse most likely see in an older adult? Select all that apply.

An older adult client is often incontinent of stool in his bed. He has started to develop an area of skin breakdown on his sacrum. In which ways does stool incontinence contribute to skin breakdown? Select all that apply.

A nurse is caring for a client with morbid obesity. Which best describes this client’s risk of skin breakdown related to their weight?

The nurse has just received a trauma client in the emergency department. The trauma assessment reveals a patent airway, breathing within normal limits, and appropriate circulation. Which of the following should be done next?

A client who is receiving radiation treatments in the head and neck complains of a dry mouth after treatment. Which of the following pieces of advice would be best for the nurse to give to this client?

The nurse is caring for a client with a head injury. The client is experiencing increasing intracranial pressure (ICP). Which of the following findings is most consistent with this condition?

A client with throat cancer is receiving radiation treatment to the head and neck and has developed xerostomia as a result. Which of the following interventions should the nurse suggest to this client?

The emergency department nurse is evaluating a head injury client by assessing the six cardinal positions of gaze. Which of the following cranial nerves are being assessed? Select all that apply.

A nurse is eating dinner in a restaurant when a person at the next table stands up and clutches her hands to her throat, making the universal sign for choking. The nurse asks the person if she is choking and she nods her head yes. She makes squeaking sounds while trying to talk and can cough. How should the nurse respond to this situation?

A client with significant stress is experiencing muscle tension and pain in the neck and shoulders. Which of the following non-pharmacological methods has been shown to relieve muscle spasms?

A nurse is performing a head-to-toe assessment of a client who is being admitted to the unit. Which of the following body systems would be included as part of the HEENT/Neuro portion of the assessment? Select all that apply.

A nurse is performing a focused assessment on the head and neck of a 3-year-old child with an upper respiratory infection. Several of the child’s lymph nodes are enlarged, indicating an infectious process, and the nurse is able to palpate many of the lymph nodes. Which of the following nodes would most likely not show up as enlarged on a head and neck exam?

A nurse is caring for an unconscious client who is recovering from a head injury. The client is sedated with an intracranial monitor in place, and the nurse is charting the client’s pain level. Which of the following pain assessment methods are appropriate in this situation? Select all that apply.

The nurse is charting a skin assessment on the newly admitted client. The client has a palpable blood filled bump on the forehead from a fall. The nurse should chart this using what terminology?

The nurse notes that the client has conductive hearing loss. Which of the following contribute to this type of hearing loss? Select all that apply.

The nurse is caring for a client with otitis media. Nursing interventions to treat this condition include which of the following? Select all that apply.

A nurse is caring for a 71-year-old client who has demonstrated some hearing loss and started to use a hearing aid. Which findings would the nurse expect if the client is using the hearing aid correctly? Select all that apply.

A client complains that he has developed a chronically dry mouth after taking his daily medication. What information can the nurse provide that would most likely help him to manage this condition?

A nurse is caring for a client who is experiencing eye movements that are out of sync with each other. Which of the following terms is appropriate for this finding?

A nurse is helping a client to remove dentures from the top of the mouth. Which best describes how the nurse should assist?

A client presents to the emergency department with a foreign object sticking out of the left eye. Which of the following is a priority intervention? Select all that apply.

A client has strabismus. Which of the following would the nurse expect to see during assessment?

The nurse is caring for a child with acute otitis media. Which of the following are appropriate nursing interventions for this child? Select all that apply.

A nurse is caring for a client who is experiencing farsightedness. The nurse knows another name for this is which of the following?

During a cardiac assessment, the nurse notes that upon auscultation of the client’s heart, the pulse is regular but the volume of the pulse diminishes every other beat. This condition is best described as which of the following?

A client who is recovering from cardiac catheterization has developed low blood pressure and jugular venous distention. The nurse auscultates the client’s chest and notes clear lung sounds, but muffled heart sounds. Which action would the nurse perform first?

The nurse is caring for a client after surgery. The client’s lung sounds are clear on the left and soft, distant crackles on the right side. The nurse reviews the image above on the morning chest x-ray. Which intervention would be most appropriate for this client?

The nurse in the trauma bay is caring for a client brought in after falling off of a roof onto a car. During the initial assessment, the resident states the client has a positive FAST exam. The nurse knows this indicates which of the following?

A client is being seen in the emergency department for abdominal pain. Based on the client’s history, the nurse believes the client may have an abdominal aortic aneurysm. Which method of physical assessment should the nurse employ in this situation?

The nurse is caring for a client who is recovering from an inguinal hernia repair. Which of the following nursing interventions are appropriate? Select all that apply.

A home care nurse is working with a client who has a self-care deficit related to a musculoskeletal disorder. The nurse notes that the home health aide who works with this client asks the client to try to eat independently as much as possible. Which of the following best describes the most likely rationale for this?

A nurse who is working on the rehabilitation unit of the hospital has been assigned the following clients: Client A is a 39-year-old who has a musculoskeletal condition that requires chiropractic alignment once a week. Client B is a 50-year-old who has vision loss and needs 1-person assist with movement. Client C is a 68-year-old who suffers from tinnitus due to an inner ear disorder. In which order should the nurse see these clients to support their needs for movement and rehabilitation?

A nurse who works in a rehabilitation unit is at the healthcare clinic for back pain. The nurse receives a diagnosis of an advanced-stage musculoskeletal injury in the lower back and has orders to remain on bed rest for the next week. Which best describes symptoms associated with an advanced stage musculoskeletal injury in this situation? Select all that apply.

The nurse is talking with a client who has just been diagnosed with Paget’s disease. The nurse knows that this is a disorder that affects which organ?

The nurse is assessing a client who reports new onset dysuria, and vaginal discharge that is green in color. The nurse suspects which of the following sexually transmitted infections?

The nurse is caring for a 35-year-old client who reports a history of syphilis infection discovered at age 25. The nurse knows that which of the following is true regarding syphilis at this stage?

The nurse is interviewing a client who reports they have a new sexual partner. The client states they have burning with urination and new-onset penile discharge that has an odor. The nurse suspects which of the following conditions?

The nurse is setting up for an examination of a client in the clinic. The nurse obtains items for the provider to conduct a papanicolaou test. What is the age range for a client receiving this test?

The nurse is performing an admission assessment on a client who claims to have multiple sexual partners. The client denies any signs or symptoms of a sexually transmitted infection. Which of the following teaching points is true for this client?