Ramont2e Rev TIF Ch19

8/20/2019 Ramont2e Rev TIF Ch19

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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 19Question 1

Type: MCSA

The nurse admits a client with the medical diagnosis of pneumonia. Which of the following will the LPN/LVN

perform

1. The head!to!toe initial assessment of the client

2. An admission assessment

. A focused assessment at the end of the shift

!. A complete ph"sical e#amination

Corre"t #ns$er: $

Rationa%e 1% The LPN/LVN most often will &e responsi&le for a focused assessment on the client once or twice a

shift. The LPN/LVN ma" &e as'ed to conduct a focused assessment of a &od" part( &ut( in this case( it would &e o

the client)s lungs( as the client has pneumonia. A head!to!toe assessment( complete ph"sical e#amination( oradmission assessment is generall" conducted &" the *N with data!collection assistance from the LPN/LVN.

Rationa%e 2% The LPN/LVN most often will &e responsi&le for a focused assessment on the client once or twice a



Rationa%e % The LPN/LVN most often will &e responsi&le for a focused assessment on the client once or twice a



Rationa%e !% The LPN/LVN most often will &e responsi&le for a focused assessment on the client once or twice a


the client)s lungs( as the client has pneumonia. A head!to!toe assessment( complete ph"sical e#amination( or

admission assessment is generall" conducted &" the *N with data!collection assistance from the LPN/LVN.

&%o'a% Rationa%e:

Cogniti(e )e(e%: Appl"ing

C%ient Need: Ph"siological +ntegrit"

C%ient Need *u':

Nursing+ntegrated Con"epts: Nursing Process% Assessment

*amont( Niedringhous( Comprehensive Nursing Care ,nd -dition pdate Test an'

Cop"right ,01, &" Pearson -ducation( +nc.



)earning -ut"ome: Name three t"pes of ph"sical health assessment and discuss the role of the LPN/LVN inhealth assessment.

Question 2

Type: MCMA

The LPN/LVN assists with admitting a client with se2ere gastric pain &" doing which of the following Select all

that appl".

*tandard Tet: Select all that appl".

1. Measuring 2ital signs

2. 3etermining the client)s current pain le2el

. Performing a head!to!toe complete admission assessment

!. As'ing the client a&out allergies

/. Administering analgesics as ordered

Corre"t #ns$er: 1(,(4(5

Rationa%e 1% The LPN/LVN ma" perform all of the tas's e#cept the complete assessment( which is theresponsi&ilit" of the *N.

Rationa%e 2% The LPN/LVN ma" perform all of the tas's e#cept the complete assessment( which is the

responsi&ilit" of the *N.

Rationa%e % The LPN/LVN ma" perform all of the tas's e#cept the complete assessment( which is the


Rationa%e !% The LPN/LVN ma" perform all of the tas's e#cept the complete assessment( which is the


Rationa%e /% The LPN/LVN ma" perform all of the tas's e#cept the complete assessment( which is the


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: Name three t"pes of ph"sical health assessment and discuss the role of the LPN/LVN inhealth assessment.





Question

Type: MCMA

The nurse conducts a focused neurological assessment of the client with a sei6ure disorder &" doing which of the

following .Select all that appl".


1. Assessing pupils for accommodation and response to light

2. Assessing general mental status

. Chec'ing grip strength &ilaterall"

!. Assessing pain status

/. Measuring 2isual acuit"

Corre"t #ns$er: 1(,($

Rationa%e 1% Mental status( pupil response( and grip strength all would &e part of a focused neurological

e#amination. Pain and 2isual acuit" assessments would not &e part of the e#am unless the client had another

pro&lem that would affect 2ision or need pain assessment.

Rationa%e 2% Mental status( pupil response( and grip strength all would &e part of a focused neurologicale#amination. Pain and 2isual acuit" assessments would not &e part of the e#am unless the client had another


Rationa%e % Mental status( pupil response( and grip strength all would &e part of a focused neurologicale#amination. Pain and 2isual acuit" assessments would not &e part of the e#am unless the client had another pro&lem that would affect 2ision or need pain assessment.

Rationa%e !% Mental status( pupil response( and grip strength all would &e part of a focused neurological

e#amination. Pain and 2isual acuit" assessments would not &e part of the e#am unless the client had another pro&lem that would affect 2ision or need pain assessment.

Rationa%e /% Mental status( pupil response( and grip strength all would &e part of a focused neurological

e#amination. Pain and 2isual acuit" assessments would not &e part of the e#am unless the client had another


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: +dentif" elements to chec' &" &od" s"stem.





Question !

Type: MCSA

While performing a focused assessment on the client( the nurse notes a s'in rash( which the nurse correctl"

documents as%

1. *ash on face( arms( and trun'.

2. Maculopapular rash o2er trun' that client sa"s itches.

. ,cm &oil noted on the client)s shoulder.

!. -r"thematous &utterfl"!shaped rash noted o2er the client)s chee's and nose.

Corre"t #ns$er: 4

Rationa%e 1% The student descri&es the color( si6e( shape( and location of the &utterfl" rash( which is correct. Rashon face, arms, and trunk does not include shape( color( or an" other properties. The &oil on the shoulder gi2es the

si6e &ut not the color or presence of drainage or discomfort. Maculopapular rash on the trun' is not specific

enough in location( and does not descri&e the color or si6e. 3ocumentation of assessment findings should &e donein such a wa" that the reader can 7see7 the finding e2en if he hasn)t "et seen the client.

Rationa%e 2% The student descri&es the color( si6e( shape( and location of the &utterfl" rash( which is correct. Rash

on face, arms, and trunk does not include shape( color( or an" other properties. The &oil on the shoulder gi2es the

si6e &ut not the color or presence of drainage or discomfort. Maculopapular rash on the trun' is not specificenough in location( and does not descri&e the color or si6e. 3ocumentation of assessment findings should &e done

in such a wa" that the reader can 7see7 the finding e2en if he hasn)t "et seen the client.

Rationa%e % The student descri&es the color( si6e( shape( and location of the &utterfl" rash( which is correct. Rash

on face, arms, and trunk does not include shape( color( or an" other properties. The &oil on the shoulder gi2es thesi6e &ut not the color or presence of drainage or discomfort. Maculopapular rash on the trun' is not specific

enough in location( and does not descri&e the color or si6e. 3ocumentation of assessment findings should &e done


Rationa%e !% The student descri&es the color( si6e( shape( and location of the &utterfl" rash( which is correct. Rashon face, arms, and trunk does not include shape( color( or an" other properties. The &oil on the shoulder gi2es the

si6e &ut not the color or presence of drainage or discomfort. Maculopapular rash on the trun' is not specific

enough in location( and does not descri&e the color or si6e. 3ocumentation of assessment findings should &e done


&%o'a% Rationa%e:



C%ient Need *u':

Nursing+ntegrated Con"epts: Nursing Process% +mplementation






Question /

Type: MCMA

The nurse conducts a focused assessment of a client)s peripheral 2ascular s"stem including which of the

following


1. Vital signs

2. Perfusion

. Capillar" refill time

!. S'in color of e#tremities

/. S'in turgor

Corre"t #ns$er: 1(,($(4

Rationa%e 1% Assessment of the peripheral 2ascular s"stem includes color( pulses( &lood pressure( and capillar"

refill time( &ut does not normall" include s'in turgor( as this is a test for h"dration.

Rationa%e 2% Assessment of the peripheral 2ascular s"stem includes color( pulses( &lood pressure( and capillar"refill time( &ut does not normall" include s'in turgor( as this is a test for h"dration.

Rationa%e % Assessment of the peripheral 2ascular s"stem includes color( pulses( &lood pressure( and capillar"refill time( &ut does not normall" include s'in turgor( as this is a test for h"dration.

Rationa%e !% Assessment of the peripheral 2ascular s"stem includes color( pulses( &lood pressure( and capillar"refill time( &ut does not normall" include s'in turgor( as this is a test for h"dration.

Rationa%e /% Assessment of the peripheral 2ascular s"stem includes color( pulses( &lood pressure( and capillar"

refill time( &ut does not normall" include s'in turgor( as this is a test for h"dration.

&%o'a% Rationa%e:

Cogniti(e )e(e%: Appl"ingC%ient Need: Ph"siological +ntegrit"

C%ient Need *u':



Question 0

Type: MCSA





The nurse preparing to auscultate the apical heart rate on the client ha2ing an annual ph"sical e#amination would

do what first

1. 3ocument client response.

2. *emo2e the co2er sheet from the client.

. Warm the &ell of the stethoscope.

!. 8&ser2e respirator" effort.

Corre"t #ns$er: $

Rationa%e 1% The nurse would use the &ell of the stethoscope( warmed in the hand for client comfort. The drape

need onl" &e remo2ed enough to &are the apical area of the chest. *espirator" effort would &e performed whenassessing respirator" rate( and documentation would &e done after auscultating heart rate.

Rationa%e 2% The nurse would use the &ell of the stethoscope( warmed in the hand for client comfort. The drape

need onl" &e remo2ed enough to &are the apical area of the chest. *espirator" effort would &e performed whenassessing respirator" rate( and documentation would &e done after auscultating heart rate.

Rationa%e % The nurse would use the &ell of the stethoscope( warmed in the hand for client comfort. The drape

need onl" &e remo2ed enough to &are the apical area of the chest. *espirator" effort would &e performed when

assessing respirator" rate( and documentation would &e done after auscultating heart rate.

Rationa%e !% The nurse would use the &ell of the stethoscope( warmed in the hand for client comfort. The drapeneed onl" &e remo2ed enough to &are the apical area of the chest. *espirator" effort would &e performed when

assessing respirator" rate( and documentation would &e done after auscultating heart rate.

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: 3iscuss preparation of client and en2ironment for e#amination.

Question

Type: MCSA

When preparing the room for an elderl" client coming to the pro2ider)s office for her annual ph"sical e#amination

the nurse would do which of the following

1. Turn the heat to 90:;.

2. Pro2ide &lan'ets for warmth.





. Turn all the &right lights on.

!. Place towels on the floor.

Corre"t #ns$er: ,

Rationa%e 1% The nurse prepares the room &" ma'ing sure all necessar" e<uipment is a2aila&le and then puts

&lan'ets in the room in case the client &ecomes chilled while waiting for ph"sician to arri2e. 90:; would &e ane#cessi2e temperature( ma'ing other clients uncomforta&le. right lights would not &e turned on until the ph"sician arri2es to perform the e#am( and towels on the floor would increase the ris' of the client)s slipping.

Rationa%e 2% The nurse prepares the room &" ma'ing sure all necessar" e<uipment is a2aila&le and then puts

&lan'ets in the room in case the client &ecomes chilled while waiting for ph"sician to arri2e. 90:; would &e an

e#cessi2e temperature( ma'ing other clients uncomforta&le. right lights would not &e turned on until the ph"sician arri2es to perform the e#am( and towels on the floor would increase the ris' of the client)s slipping.

Rationa%e % The nurse prepares the room &" ma'ing sure all necessar" e<uipment is a2aila&le and then puts



Rationa%e !% The nurse prepares the room &" ma'ing sure all necessar" e<uipment is a2aila&le and then puts



&%o'a% Rationa%e:


C%ient Need: Ph"siological +ntegrit"C%ient Need *u':

Nursing+ntegrated Con"epts: Nursing Process% Planning

)earning -ut"ome: 3iscuss preparation of client and en2ironment for e#amination.

Question

Type: MCSA

When assessing the s'in of a =5!"ear!old client the nurse identifies which of the following as a normal finding

1. Pallor of the s'in in the s'infolds of the a#illae

2. 3r" oral mucosa

. Clu&&ing of the fingernails

!. Confusion and disorientation





Corre"t #ns$er: ,

Rationa%e 1% *educed production of sali2a is part of the normal aging process( and is manifested &" dr" oralmucosa. The elderl" client should not ha2e pallor( clu&&ing of the fingernails( or confusion as a normal result of

the aging process

Rationa%e 2% *educed production of sali2a is part of the normal aging process( and is manifested &" dr" oral

mucosa. The elderl" client should not ha2e pallor( clu&&ing of the fingernails( or confusion as a normal result ofthe aging process

Rationa%e % *educed production of sali2a is part of the normal aging process( and is manifested &" dr" oral

mucosa. The elderl" client should not ha2e pallor( clu&&ing of the fingernails( or confusion as a normal result of

the aging process

Rationa%e !% *educed production of sali2a is part of the normal aging process( and is manifested &" dr" oral

mucosa. The elderl" client should not ha2e pallor( clu&&ing of the fingernails( or confusion as a normal result of

the aging process

&%o'a% Rationa%e:

Cogniti(e )e(e%: Anal"6ing


C%ient Need *u':


)earning -ut"ome: +dentif" potential 2aria&les in data &" age or condition.

Question 9

Type: MCSA

Which of the following would not &e included when the graduate LPN/LVN conducts a focused assessment of th

client)s lungs

1. 8&ser2e the chest as the client &reathes.

2. >entl" palpate the upper chest for crepitus.

. Percuss the airwa"s.

!. Auscultate for ad2entitious &reath sounds.

Corre"t #ns$er: $

Rationa%e 1% Percussion is a method of e#amination that the entr"!le2el LPN/LVN does not perform. With

training( the LPN/LVN ma" perform this method later in practice. 8&ser2ing( palpating( and auscultating would

all &e e#pectations of a focused e#amination of the lungs.





Rationa%e 2% Percussion is a method of e#amination that the entr"!le2el LPN/LVN does not perform. Withtraining( the LPN/LVN ma" perform this method later in practice. 8&ser2ing( palpating( and auscultating would

all &e e#pectations of a focused e#amination of the lungs.

Rationa%e % Percussion is a method of e#amination that the entr"!le2el LPN/LVN does not perform. With

training( the LPN/LVN ma" perform this method later in practice. 8&ser2ing( palpating( and auscultating wouldall &e e#pectations of a focused e#amination of the lungs.

Rationa%e !% Percussion is a method of e#amination that the entr"!le2el LPN/LVN does not perform. With

training( the LPN/LVN ma" perform this method later in practice. 8&ser2ing( palpating( and auscultating wouldall &e e#pectations of a focused e#amination of the lungs.

&%o'a% Rationa%e:


C%ient Need: Safe -ffecti2e Care -n2ironment

C%ient Need *u':


)earning -ut"ome: Name four methods of e#amination and state which are commonl" used &" LPNs/LVNs.

Question 13

Type: MCSA

The nurse is preparing to perform a focused assessment( using inspection( of a 10!"ear!old client admitted with

asthma. The nurse is aware that a <uiet en2ironment is &est for the assessment for which of the following reasons

1. The client might &e &othered &" noise and ha2e another attac'.

2. ?earing audi&le whee6es is an important part of inspection.

. The child)s &lood pressure will rise in a nois" en2ironment.

!. The client will not &e a&le to hear the nurse)s <uestions.

Corre"t #ns$er: ,

Rationa%e 1% The senses of hearing and smell are important aspects of inspection. The nurse would need to &e

a&le to hear inspirator" or e#pirator" whee6es of the child. The child)s &lood pressure will not li'el" &e affected

&" noise at this age( and noise would not contri&ute to another asthma attac'. Most children hear relati2el" well i

a nois" en2ironment.

Rationa%e 2% The senses of hearing and smell are important aspects of inspection. The nurse would need to &e

a&le to hear inspirator" or e#pirator" whee6es of the child. The child)s &lood pressure will not li'el" &e affected &" noise at this age( and noise would not contri&ute to another asthma attac'. Most children hear relati2el" well i






Rationa%e % The senses of hearing and smell are important aspects of inspection. The nurse would need to &ea&le to hear inspirator" or e#pirator" whee6es of the child. The child)s &lood pressure will not li'el" &e affected

&" noise at this age( and noise would not contri&ute to another asthma attac'. Most children hear relati2el" well i


Rationa%e !% The senses of hearing and smell are important aspects of inspection. The nurse would need to &ea&le to hear inspirator" or e#pirator" whee6es of the child. The child)s &lood pressure will not li'el" &e affected

&" noise at this age( and noise would not contri&ute to another asthma attac'. Most children hear relati2el" well ia nois" en2ironment.

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: Name four methods of e#amination and state which are commonl" used &" LPNs/LVNs.

Question 11

Type: MCSA

The nurse assesses the superior 2entral and dorsal left lateral aspect of the &od"( and correctl" documents which o

the following

1. Acti2e &owel sounds in all four <uadrants

2. Client complains of headache located near the forehead.

. reath sounds diminished in the left with rales noted.

!. Lower a&domen tender to the touch and slightl" distended

Corre"t #ns$er: $

Rationa%e 1% The superior aspect would &e a&o2e the waist. Ventral and dorsal surfaces include the front and &ac'

of the &od". Superior left lateral would &e the left chest( or &reath sounds. The stomach is on the superior plane(

&ut is generall" not assessed &" the nurse dorsall". The headache is in the cranial ca2it". A&dominal pro&lemswould &e descri&ed as inferior( 2entral( and either right or left upper or lower <uadrants.

Rationa%e 2% The superior aspect would &e a&o2e the waist. Ventral and dorsal surfaces include the front and &ac'of the &od". Superior left lateral would &e the left chest( or &reath sounds. The stomach is on the superior plane(


Rationa%e % The superior aspect would &e a&o2e the waist. Ventral and dorsal surfaces include the front and &ac'







Rationa%e !% The superior aspect would &e a&o2e the waist. Ventral and dorsal surfaces include the front and &ac'



&%o'a% Rationa%e:

Cogniti(e )e(e%: Anal"6ing


C%ient Need *u':


)earning -ut"ome: List common terms for identif"ing &od" parts and locations during e#amination.

Question 12

Type: MCSA

While e#amining a 14!"ear!old for spinal cur2ature( the nurse notes a slight cur2ing of the upper spine( and

documents it as which of the following

1. Slight cur2e to the right noted in the superior thoracic spine.

2. Spinal column shows a slight cur2e to the right.

. Spinal column appears to cur2e to the right.

!. Scoliosis noted on the spinal column.

Corre"t #ns$er: 1

Rationa%e 1% 3ocumenting a slight cur2e to the right on the superior thoracic spine tells others e#actl" where the

cur2e was noted. Stating that the spinal column shows a cur2e( or appears to cur2e( does not ade<uatel" descri&ethe location of the defect. Scoliosis is a medical diagnosis( and nurses do not diagnose.

Rationa%e 2% 3ocumenting a slight cur2e to the right on the superior thoracic spine tells others e#actl" where the

cur2e was noted. Stating that the spinal column shows a cur2e( or appears to cur2e( does not ade<uatel" descri&e

the location of the defect. Scoliosis is a medical diagnosis( and nurses do not diagnose.

Rationa%e % 3ocumenting a slight cur2e to the right on the superior thoracic spine tells others e#actl" where the

cur2e was noted. Stating that the spinal column shows a cur2e( or appears to cur2e( does not ade<uatel" descri&e


Rationa%e !% 3ocumenting a slight cur2e to the right on the superior thoracic spine tells others e#actl" where thecur2e was noted. Stating that the spinal column shows a cur2e( or appears to cur2e( does not ade<uatel" descri&e






&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: List common terms for identif"ing &od" parts and locations during e#amination.

Question 1

Type: MCSA

Which of the following could the nurse perform in order to reduce the an#iet" of a =0!"ear!old client a&out to

undergo a ph"sical e#amination

1. As' the client to identif" herself.

2. >i2e the client a gown to wear.

. Tell the client what will &e done throughout the e#amination.

!. Tells the client that there is no need to &e ner2ous.

Corre"t #ns$er: $

Rationa%e 1% ?elping the client to understand e#actl" what will happen reduces an#iet" caused &" fear of the

un'nown. The nurse would introduce himself to the client rather than ma'ing the client identif" herself. While

helping the client into a gown might &e a necessar" part of the preparation process( it could increase the client)sle2el of an#iet". Telling the client there is no reason to &e ner2ous negates the client)s feelings( and is a &arrier to

therapeutic relationship.

Rationa%e 2% ?elping the client to understand e#actl" what will happen reduces an#iet" caused &" fear of the

un'nown. The nurse would introduce himself to the client rather than ma'ing the client identif" herself. Whilehelping the client into a gown might &e a necessar" part of the preparation process( it could increase the client)s

le2el of an#iet". Telling the client there is no reason to &e ner2ous negates the client)s feelings( and is a &arrier to


Rationa%e % ?elping the client to understand e#actl" what will happen reduces an#iet" caused &" fear of theun'nown. The nurse would introduce himself to the client rather than ma'ing the client identif" herself. While

helping the client into a gown might &e a necessar" part of the preparation process( it could increase the client)s

le2el of an#iet". Telling the client there is no reason to &e ner2ous negates the client)s feelings( and is a &arrier to therapeutic relationship.

Rationa%e !% ?elping the client to understand e#actl" what will happen reduces an#iet" caused &" fear of the

un'nown. The nurse would introduce himself to the client rather than ma'ing the client identif" herself. While

helping the client into a gown might &e a necessar" part of the preparation process( it could increase the client)sle2el of an#iet". Telling the client there is no reason to &e ner2ous negates the client)s feelings( and is a &arrier to






&%o'a% Rationa%e:


C%ient Need: Ps"chosocial +ntegrit"

C%ient Need *u':


)earning -ut"ome: 3escri&e nursing care of the client undergoing an assessment.

Question 1!

Type: MCSA

The nurse measures the client)s &lood pressure( and the client in<uires what the reading was. The nurse does

which of the following

1. Calls the ph"sician to as' if the &lood pressure can &e shared with the client.

2. Tell the client that the doctor will &e with him shortl" to discuss his P.

. Tell the client that the &lood pressure reading must &e interpreted &" the ph"sician.

!. Tell the client what the reading was and its meaning( using it as a teaching opportunit".

Corre"t #ns$er: 4

Rationa%e 1% The client has the right to 'now what his &lood pressure reading is( and the nurse can use it as a

teaching opportunit" if it is high( discussing the need to ta'e prescri&ed medications or reduce salt inta'e in the

diet. The ph"sician does not need to &e consulted for permission to share information with the client( and it is notnecessar" for the ph"sician to interpret the results. There is no reason to ma'e the client wait to as' the ph"sician

for the P results( as the nurse is competent to pro2ide that information.

Rationa%e 2% The client has the right to 'now what his &lood pressure reading is( and the nurse can use it as a

teaching opportunit" if it is high( discussing the need to ta'e prescri&ed medications or reduce salt inta'e in thediet. The ph"sician does not need to &e consulted for permission to share information with the client( and it is not

necessar" for the ph"sician to interpret the results. There is no reason to ma'e the client wait to as' the ph"sician


Rationa%e % The client has the right to 'now what his &lood pressure reading is( and the nurse can use it as ateaching opportunit" if it is high( discussing the need to ta'e prescri&ed medications or reduce salt inta'e in the

diet. The ph"sician does not need to &e consulted for permission to share information with the client( and it is not

necessar" for the ph"sician to interpret the results. There is no reason to ma'e the client wait to as' the ph"sicianfor the P results( as the nurse is competent to pro2ide that information.

Rationa%e !% The client has the right to 'now what his &lood pressure reading is( and the nurse can use it as a

teaching opportunit" if it is high( discussing the need to ta'e prescri&ed medications or reduce salt inta'e in the

diet. The ph"sician does not need to &e consulted for permission to share information with the client( and it is notnecessar" for the ph"sician to interpret the results. There is no reason to ma'e the client wait to as' the ph"sician






&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: 3escri&e nursing care of the client undergoing an assessment.

Question 1/

Type: MCSA

The nurse documents crac'les in the lung field when which of the following is heard

1. A low!pitched snoring sound

2. A high!pitched musical sound

. Air passing through narrowed air passages

!. Air passing through fluid or mucus

Corre"t #ns$er: 4

Rationa%e 1% Air passing through fluid or mucus will sound li'e a crac'ling noise. Air passing through narrowed

passages is termed rhonchi( descri&ed as a low!pitched snoring sound. A high!pitched musical sound is whee6ing

Rationa%e 2% Air passing through fluid or mucus will sound li'e a crac'ling noise. Air passing through narrowed


Rationa%e % Air passing through fluid or mucus will sound li'e a crac'ling noise. Air passing through narrowed


Rationa%e !% Air passing through fluid or mucus will sound li'e a crac'ling noise. Air passing through narrowed passages is termed rhonchi( descri&ed as a low!pitched snoring sound. A high!pitched musical sound is whee6ing

&%o'a% Rationa%e:



C%ient Need *u':Nursing+ntegrated Con"epts: Nursing Process% Assessment

)earning -ut"ome: +dentif" terms used in ph"sical health assessment of the lungs.

Question 10

Type: MCSA





The nurse caring for a client diagnosed with pleuris" auscultates the lungs for which of the following anticipated

findings

1. ;riction ru& heard in lower left anterior chest

2. ;riction ru& heard in dorsal upper left chest

. ;riction ru& heard in middle left lo&e

!. *honchi noted in the left &ronchi

Corre"t #ns$er: 1

Rationa%e 1% ;riction ru&s most often are heard in the lower anterior lateral chest. *honchi can &e noted in an"

area of the lung( &ut generall" are not associated with pleuris".

Rationa%e 2% ;riction ru&s most often are heard in the lower anterior lateral chest. *honchi can &e noted in an"


Rationa%e % ;riction ru&s most often are heard in the lower anterior lateral chest. *honchi can &e noted in an"


Rationa%e !% ;riction ru&s most often are heard in the lower anterior lateral chest. *honchi can &e noted in an"area of the lung( &ut generall" are not associated with pleuris".

&%o'a% Rationa%e:




)earning -ut"ome: +dentif" terms used in ph"sical health assessment of the lungs.

Question 1

Type: MCSA

The nurse plans to collect data on a client who has &een admitted with mild respirator" distress secondar" to

pulmonar" edema. When planning the se<uence of the assessment( the nurse would do which of the following

1. Plan to assess the client to minimi6e position changes.

2. Perform the respirator" assessment first.

. Assess from head!to!toe.

!. egin &" assessing cardiac status.





Corre"t #ns$er: ,

Rationa%e 1% The priorit" for assessment is the respirator" s"stem &ecause this is the source of the client)s distressMinimi6ing position changes would not &e a consideration( &ecause mo2ement is 2er" important for the client

with pulmonar" edema in order to promote rea&sorption of fluid and reduce the ris' of infection. Performing a

head!to!toe or cardiac assessment would dela" data collection on the priorit" s"stem. The LPN/LVN would perform a focused assessment of the respirator" s"stem and report findings to the *N &efore continuing to collect

other data.

Rationa%e 2% The priorit" for assessment is the respirator" s"stem &ecause this is the source of the client)s distress

Minimi6ing position changes would not &e a consideration( &ecause mo2ement is 2er" important for the clientwith pulmonar" edema in order to promote rea&sorption of fluid and reduce the ris' of infection. Performing a

head!to!toe or cardiac assessment would dela" data collection on the priorit" s"stem. The LPN/LVN would

perform a focused assessment of the respirator" s"stem and report findings to the *N &efore continuing to collectother data.

Rationa%e % The priorit" for assessment is the respirator" s"stem &ecause this is the source of the client)s distress

Minimi6ing position changes would not &e a consideration( &ecause mo2ement is 2er" important for the client

with pulmonar" edema in order to promote rea&sorption of fluid and reduce the ris' of infection. Performing ahead!to!toe or cardiac assessment would dela" data collection on the priorit" s"stem. The LPN/LVN would

perform a focused assessment of the respirator" s"stem and report findings to the *N &efore continuing to collect

other data.

Rationa%e !% The priorit" for assessment is the respirator" s"stem &ecause this is the source of the client)s distressMinimi6ing position changes would not &e a consideration( &ecause mo2ement is 2er" important for the client

with pulmonar" edema in order to promote rea&sorption of fluid and reduce the ris' of infection. Performing a

head!to!toe or cardiac assessment would dela" data collection on the priorit" s"stem. The LPN/LVN would perform a focused assessment of the respirator" s"stem and report findings to the *N &efore continuing to collect

other data.

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: 3escri&e suggested se<uencing to conduct a ph"sical health assessment in an orderl"

fashion.

Question 1

Type: MCSA

The LPN/LVN ma" ha2e se2eral responsi&ilities regarding the client@s assessment( and it is most important to

'now

1. The difference &etween a complete and focused assessment





2. The scope of practice defined &" the state &oard of nursing

. Who can delegate to the LPN/LVN

!. The se<uence of assessment

Corre"t #ns$er: ,

Rationa%e 1% +t is important to 'now the difference &etween the t"pes of assessment( howe2er it is not the most

important consideration.

Rationa%e 2% The LPN/LVN must 'now and follow the scope of practice defined &" the state &oard of nursing andfacilit" polic"

Rationa%e % This is important( &ut not the most important issue

Rationa%e !% The se<uence of assessment is not primar" in this situation.

&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':


)earning -ut"ome:

Question 19

Type: MCMA

The complete assessment is done when the client is admitted to the healthcare facilit". +nformation that the

LPN/LVN ma" &e as'ed to collect includes%Select all that appl"B


1. Allergies

2. Le2el of am&ulation

. Nursing diagnoses

!. ?ead to toe assessment

/. ;all ris' assessment


Rationa%e 1% Allergies are an important piece of data to &e collected during the health histor"





Rationa%e 2% !The le2el of am&ulation and self care a&ilit" is importan data to collect curing the admissionassessment

Rationa%e % !Nursing diagnoses are determined &" an *N

Rationa%e !% !The LPN/LVN ma" &e as'ed to collect data with a ful head toe assessment

Rationa%e /% !A fall ris' assessment is an important piece of information to collect during the admissionassessment

&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':


)earning -ut"ome:

Question 23

Type: MCMA

The nurse uses each of the following assessments during the course of e2er" client@s care( including%Select all

that appl"B


1. Complete assessment

2. ;ocused assessment &" &od" s"stem

. ;ocused assessment of a &od" part

!. ;ontanel assessment

/. Pain threshold


Rationa%e 1% !

Rationa%e 2% !

Rationa%e % !

Rationa%e !% !

Rationa%e /% !





&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':


)earning -ut"ome:

Question 21

Type: MCSA

The LPN/LVN ma" ha2e se2eral responsi&ilities regarding the client@s assessment( and it is most important to

'now

1. The difference &etween a complete and focused assessment

2. The scope of practice defined &" the state &oard of nursing

. Who can delegate to the LPN/LVN

!. The se<uence of assessment

Corre"t #ns$er: ,

Rationa%e 1% +t is important to 'now the difference &etween the t"pes of assessment( howe2er it is not the most


Rationa%e 2% The LPN/LVN must 'now and follow the scope of practice defined &" the state &oard of nursing and

facilit" polic"

Rationa%e % This is important( &ut not the most important issue


&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':


)earning -ut"ome:

Question 22

Type: MCMA






LPN/LVN ma" &e as'ed to collect includes%Select all that appl"B


1. Allergies

2. Le2el of am&ulation

. Nursing diagnoses

!. ?ead to toe assessment

/. ;all ris' assessment


Rationa%e 1% Allergies are an important piece of data to &e collected during the health histor"

Rationa%e 2% !The le2el of am&ulation and self care a&ilit" is importan data to collect curing the admission

assessment

Rationa%e % !Nursing diagnoses are determined &" an *N

Rationa%e !% !The LPN/LVN ma" &e as'ed to collect data with a ful head toe assessment

Rationa%e /% !A fall ris' assessment is an important piece of information to collect during the admissionassessment

&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':


)earning -ut"ome:

Question 2

Type: MCMA

The nurse uses each of the following assessments during the course of e2er" client@s care( including%Select all

that appl"B


1. Complete assessment





2. ;ocused assessment &" &od" s"stem

. ;ocused assessment of a &od" part

!. ;ontanel assessment

/. Pain threshold


Rationa%e 1% !

Rationa%e 2% !

Rationa%e % !

Rationa%e !% !

Rationa%e /% !

&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':


)earning -ut"ome:

Question 2!Type: MCMA

The LPN/LVN is performing a focused assessment on the client with a draining wound. +nformation that will &e

collected includes%Select all that appl"B


1. S'in integrit"

2. 8dor noted

. Vital signs

!. +nta'e and output

/. S"mmetr" of chest mo2ements






Rationa%e 1% The progress of wound healing( or lac' thereof is information that needs to &e o&tained anddocumented

Rationa%e 2% 8dor emanating from the wound ma" indicate infection

Rationa%e % Vital signs are important to o&tain to determine if there are s"stemic signs of infection

Rationa%e !% +f the wound is draining copious amounts of fluid( the client is at ris' for fluid im&alance

Rationa%e /% S"mmetr" of chest mo2ements is not part of the focused assessment of the wound

&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':

Nursing+ntegrated Con"epts:

)earning -ut"ome:

Question 2/

Type: MCSA

A client who has &een a resident of the long term care facilit" for months is complaining of shortness of &reath.

The nurse will perform a focused assessment that includes%

1. Auscultation of the h"pogastric region

2. Clients lifest"le

. se of a pulse o#imeter

!. Shape of pupils

Corre"t #ns$er: $

Rationa%e 1% The

Rationa%e 2% The

Rationa%e % The

Rationa%e !% The

&%o'a% Rationa%e:


C%ient Need:





C%ient Need *u':


)earning -ut"ome:

Question 20

Type: MCSA

At the end of the shift the nurse performs a focused assessment &" &od" s"stem. +nformation that is important to

collect includes all of the following e#cept%

1. eha2ior

2. *espirator" rate

. Le2el of comfort

!. 3ietar" ha&its

Corre"t #ns$er: 4

Rationa%e 1% +nteractions with the client are important to assess for appropriateness

Rationa%e 2% The client@s respirator" status is important to assess each shift or more often

Rationa%e % The client@s comfort is important to assess and document

Rationa%e !% The client@s dietar" ha&its are part of a complete health histor"( not a dail" focused assessment

&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':


)earning -ut"ome:

Question 2

Type: MCMA

The nurse is performing a focused assessment of the client@s gastrointestinal status. Appropriate data to collect

would include%Select all that appl"B


1. owel sounds





2. Appetite

. *ange of motion

!. Characteristics of emesis

/. Presence of whee6ing

Corre"t #ns$er: 1(,(4

Rationa%e 1% Auscultation of &owel sounds in all four <uadrants is appropriate data to collect and document

Rationa%e 2% +nformation regarding the client@s appetite and percentage of inta'e of meals is important

information to collect and document

Rationa%e % *ange of motion is appropriate information to collect and document in the musculos'eletal

assessment

Rationa%e !% The amount( ( color and fre<uenc" of emesis is important data to collect and document

Rationa%e /% The presence of whee6ing is appropriate data to collect and document in the respirator" assessment

&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':


)earning -ut"ome:

Question 2

Type: MCMA

When the nurse is performing an admission ph"sical assessment on the pediatric client who is under $0 da"s old(

additional data to note includes%Select all that appl"B


1. Shape of head

2. Presence of &arrel!chested appearance

. As"mmetric gluteal folds

!. Presence of receding gums

/. -#cursion s"mmetr" or as"mmetr" of chest on respiration





Corre"t #ns$er: 1($

Rationa%e 1% The shape of the infants head should onl" &e altered &" 2aginal deli2er" for a&out 1 wee'D longerthan that ma" need follow up

Rationa%e 2% The shape of the infants head should onl" &e altered &" 2aginal deli2er" for a&out 1 wee'D longer

than that ma" need follow up

Rationa%e % The shape of the infants head should onl" &e altered &" 2aginal deli2er" for a&out 1 wee'D longerthan that ma" need follow up

Rationa%e !% The shape of the infants head should onl" &e altered &" 2aginal deli2er" for a&out 1 wee'D longer


Rationa%e /% The shape of the infants head should onl" &e altered &" 2aginal deli2er" for a&out 1 wee'D longer


&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':


)earning -ut"ome:

Question 29

Type: MCMA

The LPN/LVN is preparing to perform a focused assessment &" &od" s"stem. Appropriate actions include%Selectall that appl"B


1. -#plaining the procedure

2. +nstructing clients to retain urine for the procedure

. 8rgani6ing the assessment so that se2eral &od" areas can &e assessed in one position

!. Pro2iding for pri2ac"

/. Preparing e<uipment

Corre"t #ns$er: 1($(4(5

Rationa%e 1% -#plaining the procedure will decrease client an#iet" and increase the client@s a&ilit" to cooperate

with the procedure





Rationa%e 2% The clients should &e instructed to empt" their &ladders prior to the e#aminationD this facilitates palpation of the a&domen and pu&ic area( and helps them feel more comforta&le

Rationa%e % Se2eral positions ma" &e necessar" for the client to assume during a ph"sical assessmentD the

client@s ph"sical condition( energ" le2el( and age should &e ta'en into consideration

Rationa%e !% 3raping the client with &ed linens e#poses one area at a time( pro2iding pri2ac" and warmth

Rationa%e /% Preparing all e<uipment necessar" for the assessment prior to &eginning will ma'e the client andnurse more comforta&le( and facilitate the procedure

&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':


)earning -ut"ome:

Question 3

Type: MCSA

The nursing student is preparing to perform a ph"sical e#amination of the adult client. The techni<ues the student

will not utili6e is%

1. Smelling

2. Auscultation

. Percussion

!. Palpation

Corre"t #ns$er: $

Rationa%e 1% The student will use olfactor" and auditor" cues( as well as 2isual o&ser2ation

Rationa%e 2% The student will use olfactor" and auditor" cues( as well as 2isual o&ser2ation

Rationa%e % The student will use olfactor" and auditor" cues( as well as 2isual o&ser2ation

Rationa%e !% The student will use olfactor" and auditor" cues( as well as 2isual o&ser2ation

&%o'a% Rationa%e:

Cogniti(e )e(e%:

C%ient Need:





C%ient Need *u':


)earning -ut"ome:

Question 1

Type: MCMA

A client is admitted to the postoperati2e unit in the acute care hospital. The nurse gathers data using inspection(

such as


1. Color of the s'in and mucous mem&ranes

2. Nail &ed color

. ?air growth

!. *espirator" rate

/. ;ragilit" of &ones


Rationa%e 1% The color of &od" surfaces can &e assessed using 2isual inspection

Rationa%e 2% Nail &eds can &e assessed &" inspection

Rationa%e % Patterns of hair growth( or lac' of hair can &e assessed 2isuall"

Rationa%e !% *espirator" rate can &e determined &" o&ser2ing the rise and fall of the chest

Rationa%e /% ;ragilit" of &ones cannot &e assessed 2isuall"

&%o'a% Rationa%e:



C%ient Need *u':

Nursing+ntegrated Con"epts: Nursing Process% Assessment)earning -ut"ome:

Question 2

Type: MCMA

The nursing student is o&ser2ing the LPN/LVN performing auscultation during a ph"sical e#amination. Areas of

the &od" for which auscultation is appropriate include%






1. ?eart

2. A&domen

. S'ull

!. Nec'

/. ?ands


Rationa%e 1% The nurse uses a stethoscope to listen to heart sounds

Rationa%e 2% The nurse uses a stethoscope to listen to &owel sounds

Rationa%e % Auscultation is not used on the s'ull

Rationa%e !% Auscultation can &e used on the nec' to assess carotid arteries

Rationa%e /% Auscultation cannot &e used on the hands

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question

Type: MCMA

While assessing the child( the nurse uses palpation to assess%Select all that appl"B


1. Te#ture of hair

2. Temperature

. Vi&ration

!. Mo&ilit"





/. Color


Rationa%e 1% Te#ture of hair can &e assessed using palpation

Rationa%e 2% Temperature of s'in can &e assessed using palpation

Rationa%e % Vi&ration of Eoints and &lood 2essels can &e assessed using palpation

Rationa%e !% Mo&ilit" of Eoints can &e assessed using touch and palpation

Rationa%e /% Color is assessed using 2isual inspection

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question !

Type: MCSA

Light palpation is used &" the LPN/LVN to assess%Select all that appl"B

1. 3istension of the &ladder

2. ?elp the client to clear the respirator" tract

. Mo&ilit" of organs

!. Si6e of organs

Corre"t #ns$er: 1

Rationa%e 1% The LPN/LVN uses light palpation to assess distention of the &ladder or a&domen

Rationa%e 2% Percussion is used to help the client to clear the respirator" tract

Rationa%e % 3eep palpation is used to assess mo&ilit" of organs( and is not usuall" done &" the LPN/LVN

Rationa%e !% 3eep palpation is used to assess the si6e of organs( and is not usuall" done &" the LPN/LVN

&%o'a% Rationa%e:







C%ient Need *u':


)earning -ut"ome:

Question /

Type: S-F

The nurse prepares to collect data for assessment &" organi6ing the necessar" e<uipment( and preparing the

en2ironment. +n the focused ph"sical assessment &" &od" s"stem( the nurse will follow a general order. Place the

following assessments in the most appropriate order from first inter2ention to last inter2ention.

*tandard Tet: Clic' and drag the options &elow to mo2e them up or down.

Choi"e 1. >eneral appearance

Choi"e 2. Attitude of client

Choi"e . Le2el of consciousness and orientation

Choi"e !. Assessing motor response

Choi"e /. +nspection of s'in

Choi"e 0. Cardio2ascular assessment

Choi"e . +nspecting thora# and lungs

Choi"e . A&dominal assessment

Corre"t #ns$er: 1(,($(4(5((=(9

Rationa%e 1% The nurse &egins ph"sical assessment with a general sur2e" of clients appearance

Rationa%e 2% The nurse follows the appearance assessment with the assessment of the general attitude and &eha2ior of the client

Rationa%e % ;ollowing the general sur2e"( the nurse e2aluates the le2el of consciousness and orientation(

including the use of the >lasgow Coma Scale

Rationa%e !% ;ollowing the L8C assessment( the nurse assess the clients motor responses to simple commands(

and e2aluates the client@s gait

Rationa%e /% The assessment of the integumentar" s"stem is performed using inspection and palpation





Rationa%e 0% Cardio2ascular assessment follows the integumentar" s"stem( e2aluating heart sounds( and peripheral 2ascular s"stem

Rationa%e % +nspection( palpation and auscultation of the thora# and lungs allows the nurse to identif" de2iations

from normal respirator" status

Rationa%e % A&dominal assessment is performed &" first inspecting( then using auscultation( followed &"

palpation

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 0

Type: MCMA

The nurse is performing a ph"sical assessment on an elderl" client. The nurse e2aluates the muscular s'eletal

s"stem( understanding that the following ma" &e normal in the geriatric client%Select all that appl"B


1. -lderl" clients ha2e decreased *8M

2. -lderl" clients ha2e decreased su&cutaneous fat that ma" affect a&ilit" to sta" warm

. Vigorous assessment techni<ues such as hopping on one foot is appropriate

!. -2aluation of a&ilit" to carr" out A3Ls ma" indicate a de2iation from normal in the musculos'eletal s"stemassessment

/. Warmth in one or more Eoints

Corre"t #ns$er: 1(4

Rationa%e 1% -lderl" clients ma" ha2e decreased *8M

Rationa%e 2% -lderl" clients ma" ha2e decreased *8M

Rationa%e % -lderl" clients ma" ha2e decreased *8M

Rationa%e !% -lderl" clients ma" ha2e decreased *8M

Rationa%e /% -lderl" clients ma" ha2e decreased *8M





&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question

Type: S-F

When performing a&dominal assessments( the nurse follows a specific order of e#amination. List the following

techni<ues from first to last%


Choi"e 1. +nspection

Choi"e 2. Auscultation

Choi"e . Palpation


Rationa%e 1% The nurse inspects the a&domen for s'in integrit"( contour and s"mmetr"

Rationa%e 2% The nurse then auscultates the a&domen for &owel sounds and 2ascular sounds

Rationa%e % Palpation is performed last( as the stimulation of the intestines ma" alter the &owel sounds.

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question

Type: MCSA

While performing the focused assessment of the client with a urinar" tract infection( the nurse will first assess the

client for%

1. Color of urine





2. 3istended &ladder

. Continence

!. ;re<uenc"

Corre"t #ns$er: $

Rationa%e 1% The nurse does not assess the color of the urine first

Rationa%e 2% The nurse will palpate the area a&o2e the pu&ic s"mph"sis if the client@s histor" indicates possi&le

urinar" retention

Rationa%e % Assessing the client for continence and independent urination is the first step in the genitourinar"assessment

Rationa%e !% ;re<uenc" is not the first characteristic of the genitourinar" assessment that the nurse will assess

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 9

Type: S-F

The nurse is preparing to assess the s'in of a client with a histor" of ec6ema. The assessment will follow a logica

se<uence. Place the following in the appropriate order


Choi"e 1. +nspect s'in color

Choi"e 2. +nspect uniformit" of s'in color

Choi"e . +nspect and descri&e s'in lesions

Choi"e !. 8&ser2e and palpate s'in moisture

Choi"e /. Palpate s'in temperature

Choi"e 0. Note s'in turgor

Corre"t #ns$er: 1(,($(4(5(





Rationa%e 1% Visual inspection of s'in color is step one in the integumentar" assessment


Rationa%e % Visual inspection of s'in color is step one in the integumentar" assessment

Rationa%e !% Visual inspection of s'in color is step one in the integumentar" assessment

Rationa%e /% Visual inspection of s'in color is step one in the integumentar" assessment


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question !3

Type: MCMA

The *N ma" delegate to LPNs/LVNs a 2ariet" of data!collecting tas's( including%Select all that appl"B


1. The focused assessment at the &eginning of the shift

2. The focused assessment at the end of the shift

. The focused assessment of a &od" part in relation to client complaints

!. Specific assessment of the nurseing inter2ention pro2ided

/. 3etermination of nursing diagnosis related to assessment data


Rationa%e 1% N8 ;--3ACG

Rationa%e 2% N8 ;--3ACG

Rationa%e % N8 ;--3ACG

Rationa%e !% N8 ;--3ACG





Rationa%e /% N8 ;--3ACG

&%o'a% Rationa%e:

Cogniti(e )e(e%:

C%ient Need:

C%ient Need *u':


)earning -ut"ome:

Question !1

Type: MCMA

+nformation that the LPN/LVN ma" collect during a complete health histor" includes


1. Vital signs

2. 3ietar" ha&its

. +mpairments

!. Medication histor"

/. ?eight

Corre"t #ns$er: ,($(4

Rationa%e 1% !

Rationa%e 2% !

Rationa%e % !

Rationa%e !% !

Rationa%e /% !

&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':


)earning -ut"ome:





Question !2

Type: MCSA

The LPN/LVN can ha2e se2eral responsi&ilities regarding the client@s assessment( and it is most important to

'now%

1. The difference &etween a complete and focused assessment.

2. The scope of practice defined &" the state &oard of nursing.

. Who can delegate to the LPN/LVN.

!. The se<uence of assessment.

Corre"t #ns$er: ,

Rationa%e 1% +t is important to 'now the difference &etween the t"pes of assessmentD howe2er( it is not the most


Rationa%e 2% The LPN/LVN must 'now and follow the scope of practice defined &" the state &oard of nursing andfacilit" polic".

Rationa%e % This is important( &ut not the most important issue.


&%o'a% Rationa%e:

Cogniti(e )e(e%: Gnowledge


C%ient Need *u':


)earning -ut"ome:

Question !

Type: MCMA


LPN/LVN might &e as'ed to collect includes%


1. Allergies.

2. Le2el of am&ulation.

. Nursing diagnoses.

!. ?ead!to!toe assessment.





/. ;all ris' assessment.


Rationa%e 1% Allergies are an important piece of data to &e collected during the health histor".

Rationa%e 2% !The le2el of am&ulation and self!care a&ilit" are important data to collect curing the admission

assessment.

Rationa%e % !Nursing diagnoses are determined &" an *N.

Rationa%e !% !The LPN/LVN might &e as'ed to collect data with a full head!to!toe assessment.

Rationa%e /% !A fall ris' assessment is an important piece of information to collect during the admissionassessment.

&%o'a% Rationa%e:



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Question !!

Type: MCMA

The nurse uses each of the following assessments during the course of e2er" client@s care( including%


1. Complete assessment.

2. ;ocused assessment &" &od" s"stem.

. ;ocused assessment of a &od" part.

!. ;ontanel assessment.

/. Pain threshold.


Rationa%e 1%

Rationa%e 2%

Rationa%e %





Rationa%e !%

Rationa%e /%

&%o'a% Rationa%e:




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Question !/

Type: MCSA

The LPN/LVN can ha2e se2eral responsi&ilities regarding the client@s assessment( and it is most important to

'now%

1. The difference &etween a complete and focused assessment.

2. The scope of practice defined &" the state &oard of nursing.

. Who can delegate to the LPN/LVN.

!. The se<uence of assessment.

Corre"t #ns$er: ,

Rationa%e 1% +t is important to 'now the difference &etween the t"pes of assessmentD howe2er( it is not the most


Rationa%e 2% The LPN/LVN must 'now and follow the scope of practice defined &" the state &oard of nursing and

facilit" polic".

Rationa%e % This is important( &ut not the most important issue.


&%o'a% Rationa%e:

Cogniti(e )e(e%: GnowledgeC%ient Need: Ph"siological +ntegrit"

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Question !0

Type: MCMA





The LPN/LVN is performing a focused assessment on the client with a draining wound. +nformation that will &ecollected includes%


1. S'in integrit".

2. 8dor noted.

. Vital signs.

!. +nta'e and output.

/. S"mmetr" of chest mo2ements.


Rationa%e 1% The progress of wound healing( or lac' thereof( is information that needs to &e o&tained and

documented.

Rationa%e 2% 8dor emanating from the wound could indicate infection.

Rationa%e % Vital signs are important to o&tain to determine whether there are s"stemic signs of infection.

Rationa%e !% +f the wound is draining copious amounts of fluid( the client is at ris' for fluid im&alance.

Rationa%e /% S"mmetr" of chest mo2ements is not part of the focused assessment of the wound.

&%o'a% Rationa%e:



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Question !

Type: MCSA

A client who has &een a resident of the long!term care facilit" for months is complaining of shortness of &reath.

The nurse will perform a focused assessment that includes%

1. Auscultation of the h"pogastric region.

2. Client@s lifest"le.

. se of a pulse o#imeter.





!. Shape of pupils.

Corre"t #ns$er: $

Rationa%e 1%

Rationa%e 2%

Rationa%e %

Rationa%e !%

&%o'a% Rationa%e:



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Question !

Type: MCSA

At the end of the shift( the nurse performs a focused assessment &" &od" s"stem. +nformation that is important to

collect includes all of the following e#cept%

1. eha2ior.

2. *espirator" rate.

. Le2el of comfort.

!. 3ietar" ha&its.

Corre"t #ns$er: 4

Rationa%e 1% +nteractions with the client are important to assess for appropriateness.

Rationa%e 2% The client@s respirator" status is important to assess each shift or more often.

Rationa%e % The client@s comfort is important to assess and document.

Rationa%e !% The client@s dietar" ha&its are part of a complete health histor"( not a dail" focused assessment.

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Question !9

Type: MCMA

The nurse is performing a focused assessment of the client@s gastrointestinal status. Appropriate data to collect

would include%


1. owel sounds.

2. Appetite.

. *ange of motion.

!. Characteristics of emesis.

/. Presence of whee6ing.


Rationa%e 1% Auscultation of &owel sounds in all four <uadrants is appropriate data to collect and document.

Rationa%e 2% +nformation regarding the client@s appetite and percentage of inta'e of meals is importantinformation to collect and document.

Rationa%e % *ange of motion is appropriate information to collect and document in the musculos'eletalassessment.

Rationa%e !% The amount( color( and fre<uenc" of emesis are important data to collect and document.

Rationa%e /% The presence of whee6ing is appropriate data to collect and document in the respirator" assessment

&%o'a% Rationa%e:




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Question /3

Type: MCMA

When the nurse is performing an admission ph"sical assessment on the pediatric client who is "ounger than $0

da"s old( additional data to note include%






1. Shape of the head.

2. Presence of &arrel!chested appearance.

. As"mmetric gluteal folds.

!. Presence of receding gums.

/. -#cursion s"mmetr" or as"mmetr" of chest on respiration.

Corre"t #ns$er: 1($

Rationa%e 1% The shape of the infant@s head should &e altered &" 2aginal deli2er" for onl" a&out 1 wee'D longerthan that might need follow!up.

Rationa%e 2% The shape of the infant@s head should &e altered &" 2aginal deli2er" for onl" a&out 1 wee'D longer

than that might need follow!up.

Rationa%e % The shape of the infant@s head should &e altered &" 2aginal deli2er" for onl" a&out 1 wee'D longer


Rationa%e !% The shape of the infant@s head should &e altered &" 2aginal deli2er" for onl" a&out 1 wee'D longer


Rationa%e /% The shape of the infant@s head should &e altered &" 2aginal deli2er" for onl" a&out 1 wee'D longer


&%o'a% Rationa%e:



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Question /1

Type: MCMA

The LPN/LVN is preparing to perform a focused assessment &" &od" s"stem. Appropriate actions include%


1. -#plaining the procedure.

2. +nstructing clients to retain urine for the procedure.





. 8rgani6ing the assessment so that se2eral &od" areas can &e assessed in one position.

!. Pro2iding for pri2ac".

/. Preparing e<uipment.

Corre"t #ns$er: 1($(4(5

Rationa%e 1% -#plaining the procedure will decrease client an#iet" and increase the client@s a&ilit" to cooperate

with the procedure.

Rationa%e 2% The client should &e instructed to empt" his &ladders prior to the e#aminationD this facilitates palpation of the a&domen and pu&ic area( and helps him feel more comforta&le.

Rationa%e % Se2eral positions might &e necessar" for the client to assume during a ph"sical assessmentD the

client@s ph"sical condition( energ" le2el( and age should &e ta'en into consideration.

Rationa%e !% 3raping the client with &ed linens e#poses one area at a time( pro2iding pri2ac" and warmth.

Rationa%e /% Preparing all e<uipment necessar" for the assessment prior to &eginning will ma'e the client andnurse more comforta&le( and facilitate the procedure.

&%o'a% Rationa%e:



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Question /2

Type: MCSA

The nursing student is preparing to perform a ph"sical e#amination of the adult client. The techni<ue the studentwill not utili6e is%

1. Smelling.

2. Auscultation.

. Percussion.

!. Palpation.

Corre"t #ns$er: $

Rationa%e 1% The student will use olfactor" and auditor" cues( as well as 2isual o&ser2ation.





Rationa%e 2% The student will use olfactor" and auditor" cues( as well as 2isual o&ser2ation.

Rationa%e % The student will use olfactor" and auditor" cues( as well as 2isual o&ser2ation.

Rationa%e !% The student will use olfactor" and auditor" cues( as well as 2isual o&ser2ation.

&%o'a% Rationa%e:



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Question /

Type: MCMA

A client is admitted to the postoperati2e unit in the acute care hospital. The nurse gathers data using inspection(

such as%


1. Color of the s'in and mucous mem&ranes.

2. Nail &ed color.

. ?air growth.

!. *espirator" rate.

/. ;ragilit" of &ones.


Rationa%e 1% The color of &od" surfaces can &e assessed using 2isual inspection.

Rationa%e 2% Nail &eds can &e assessed &" inspection.

Rationa%e % Patterns of hair growth( or lac' of hair( can &e assessed 2isuall".

Rationa%e !% *espirator" rate can &e determined &" o&ser2ing the rise and fall of the chest.

Rationa%e /% ;ragilit" of &ones cannot &e assessed 2isuall".

&%o'a% Rationa%e:







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Question /!

Type: MCMA

The nursing student is o&ser2ing the LPN/LVN performing auscultation during a ph"sical e#amination. Areas of

the &od" for which auscultation is appropriate include the%


1. ?eart.

2. A&domen.

. S'ull.

!. Nec'.

/. ?ands.


Rationa%e 1% The nurse uses a stethoscope to listen to heart sounds.

Rationa%e 2% The nurse uses a stethoscope to listen to &owel sounds.

Rationa%e % Auscultation is not used on the s'ull.

Rationa%e !% Auscultation can &e used on the nec' to assess carotid arteries.

Rationa%e /% Auscultation cannot &e used on the hands.

&%o'a% Rationa%e:



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Question //

Type: MCMA

While assessing the child( the nurse uses palpation to assess%






1. Te#ture of hair.

2. Temperature.

. Vi&ration.

!. Mo&ilit".

/. Color.


Rationa%e 1% Te#ture of hair can &e assessed using palpation.

Rationa%e 2% Temperature of s'in can &e assessed using palpation.

Rationa%e % Vi&ration of Eoints and &lood 2essels can &e assessed using palpation.

Rationa%e !% Mo&ilit" of Eoints can &e assessed using touch and palpation.

Rationa%e /% Color is assessed using 2isual inspection.

&%o'a% Rationa%e:



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Question /0

Type: MCSA

Light palpation is used &" the LPN/LVN %

1. To assess distension of the &ladder.

2. To help the client to clear the respirator" tract.

. To assess mo&ilit" of organs.

!. To assess si6e of organs.

Corre"t #ns$er: 1

Rationa%e 1% The LPN/LVN uses light palpation to assess distention of the &ladder or a&domen.

Rationa%e 2% Percussion is used to help the client to clear the respirator" tract.





Rationa%e % 3eep palpation is used to assess mo&ilit" of organs( and is not usuall" done &" the LPN/LVN.

Rationa%e !% 3eep palpation is used to assess the si6e of organs( and is not usuall" done &" the LPN/LVN.

&%o'a% Rationa%e:




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Question /

Type: S-F

The nurse prepares to collect data for assessment &" organi6ing the necessar" e<uipment and preparing the

en2ironment. +n the focused ph"sical assessment &" &od" s"stem( the nurse will follow a general order. Place the

following assessments in the most appropriate order from first inter2ention to last inter2ention%


Choi"e 1. >eneral appearance

Choi"e 2. Attitude of client

Choi"e . Le2el of consciousness and orientation

Choi"e !. Motor response

Choi"e /. S'in

Choi"e 0. Cardio2ascular

Corre"t #ns$er: 1(,($(4(5(

Rationa%e 1% The nurse &egins ph"sical assessment with a general sur2e" of the client@s appearance.


Rationa%e % The nurse &egins ph"sical assessment with a general sur2e" of the client@s appearance.

Rationa%e !% The nurse &egins ph"sical assessment with a general sur2e" of the client@s appearance.

Rationa%e /% The nurse &egins ph"sical assessment with a general sur2e" of the client@s appearance.


&%o'a% Rationa%e:







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Question /

Type: MCMA

The nurse is performing a ph"sical assessment on an elderl" client. The nurse e2aluates the muscular s'eletals"stem( understanding that the following might &e t"pical in the geriatric client%


1. -lderl" clients ha2e decreased *8M.

2. -lderl" clients ha2e decreased su&cutaneous fat that can affect their a&ilit" to sta" warm.

. Vigorous assessment techni<ues such as hopping on one foot are appropriate.

!. -2aluation of the a&ilit" to carr" out A3Ls can indicate a de2iation from normal in the musculos'eletal s"stem

assessment.

/. Warmth in one or more Eoints.

Corre"t #ns$er: 1(4

Rationa%e 1% -lderl" clients can ha2e decreased *8M.

Rationa%e 2% -lderl" clients can ha2e decreased *8M.

Rationa%e % -lderl" clients can ha2e decreased *8M.

Rationa%e !% -lderl" clients can ha2e decreased *8M.

Rationa%e /% -lderl" clients can ha2e decreased *8M.

&%o'a% Rationa%e:


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Question /9

Type: S-F





When performing a&dominal assessments( the nurse follows a specific order of e#amination. List the followingtechni<ues from first to last%


Choi"e 1. +nspection

Choi"e 2. Auscultation

Choi"e . Palpation


Rationa%e 1% The nurse inspects the a&domen for s'in integrit"( contour( and s"mmetr".

Rationa%e 2% The nurse then auscultates the a&domen for &owel sounds and 2ascular sounds.

Rationa%e % Palpation is performed last( as the stimulation of the intestines can alter the &owel sounds.

&%o'a% Rationa%e:



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Question 03

Type: MCSAWhile performing the focused assessment of the client with a urinar" tract infection( the nurse first will assess theclient for%

1. Color of urine.

2. 3istended &ladder.

. Continence.

!. ;re<uenc".

Corre"t #ns$er: $

Rationa%e 1% The nurse does not assess the color of the urine first.

Rationa%e 2% The nurse will palpate the area a&o2e the client@s pu&ic s"mph"sis if the client@s histor" indicates

possi&le urinar" retention.





Rationa%e % Assessing the client for continence and independent urination is the first step in the genitourinar"assessment.

Rationa%e !% ;re<uenc" is not the first characteristic of the genitourinar" assessment that the nurse will assess.

&%o'a% Rationa%e:


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Question 01

Type: S-F

The nurse is preparing to assess the s'in of a client with a histor" of ec6ema. The assessment will follow a logica

se<uence. Place the following in the appropriate order%


Choi"e 1. +nspect s'in color.

Choi"e 2. +nspect uniformit" of s'in color.

Choi"e . +nspect and descri&e s'in lesions.

Choi"e !. 8&ser2e and palpate s'in moisture.

Choi"e /. Palpate s'in temperature.

Choi"e 0. Note s'in turgor.

Corre"t #ns$er: 1(,($(4(5(

Rationa%e 1% Visual inspection of s'in color is step one in the integumentar" assessment.


Rationa%e % Visual inspection of s'in color is step one in the integumentar" assessment.

Rationa%e !% Visual inspection of s'in color is step one in the integumentar" assessment.

Rationa%e /% Visual inspection of s'in color is step one in the integumentar" assessment.


&%o'a% Rationa%e:







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Question 02

Type: MCMA

The *N ma" delegate to LPNs/LVNs a 2ariet" of data!collecting tas's( including%


1. The focused assessment at the &eginning of the shift.

2. The focused assessment at the end of the shift.

. The focused assessment of a &od" part in relation to client complaints.

!. Specific assessment of the nursing inter2ention pro2ided.

/. 3etermination of nursing diagnosis related to assessment data.


Rationa%e 1%

Rationa%e 2%

Rationa%e %

Rationa%e !%

Rationa%e /%

&%o'a% Rationa%e:




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Question 0

Type: MCMA

+nformation that the LPN/LVN ma" collect during a complete health histor" includes%






1. Vital signs.

2. 3ietar" ha&its.

. +mpairments.

!. Medication histor".

/. ?eight.

Corre"t #ns$er: ,($(4

Rationa%e 1%

Rationa%e 2%

Rationa%e %

Rationa%e !%

Rationa%e /%

&%o'a% Rationa%e:

Cogniti(e )e(e%:


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Ramont2e Rev TIF Ch19

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Transcript of Ramont2e Rev TIF Ch19