A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which
of the following findings does the nurse expect to note if
... [Show More] cholecystitis is present?
A. Homan sign
B. Murphy sign Correct
C. Blumberg sign
D. McBurney sign
Rationale: The Murphy sign is an indicator of gallbladder disease. The client is asked to inhale
while the examiner’s fingers are hooked under the liver border, at the bottom of the rib cage.
Inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder
is inflamed. The Homan sign is pain in the calf area on sharp dorsiflexion of the client’s foot. The
Blumberg sign is the presence of rebound tenderness on palpation of the abdomen. Rebound
tenderness is a reliable sign of peritoneal irritation. The McBurney sign is a reaction of the client
indicating severe pain and extreme tenderness when the McBurney point (midway between the
umbilicus and the anterior iliac crest in the right lower quadrant of the abdomen) is palpated.
Such a reaction indicates appendicitis.
2.ID: 383733763
A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that
the client's pulse is normal. Which of the following notations would the nurse make in the client's
record to document the force of the client's pulse?
E. 4+F. 3+
G. 2+ Correct
H. 1+
Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry
of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A
4point scale may be used to assess the force (amplitude) of the pulse: 4+, bounding pulse; 3+,
increased pulse; 2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the
client’s pulse as 2+.
3.ID: 383732836
A nurse performing a physical examination is assessing the client for costovertebral angle
tenderness. When the nurse percusses the area, the client complains of sharp pain. The nurse
interprets this finding as most indicative of:
I. Liver enlargement
J. Ovarian infection
K. Spleen enlargement
L. Kidney inflammation Correct
Rationale: When assessing for costovertebral angle tenderness, the nurse is checking for kidney
tenderness. Sharp pain that occurs on percussion of the costovertebral angle indicates
inflammation of the kidney or paranephric area. To assess the kidney, the nurse places one
hand over the 12th rib, at the costovertebral angle, on the back. The nurse then thumps that
hand with the ulnar edge of the other fist. The client normally feels a thud and should notexperience pain. Ovarian infection, liver, or spleen enlargement are not associated with the
costovertebral angle.
4.ID: 383733729
A nurse performing a neurological examination is testing the cochlear portion of the acoustic
nerve (cranial nerve VIII). Which of the following actions does the nurse take to test this nerve?
M. Asking the client to raise his or her eyebrows and looking for symmetry
N. Asking the client to clench the teeth, then palpating the masseter muscles just
above the mandibular angle
O. Asking the client to close the eyes and then identify light and sharp touch with a
cotton ball and a pin on both sides of the face
P. Asking the client to close his or her eyes and then indicate when a ticking watch
is heard as the nurse brings the watch closer to the client's ear Correct
Rationale: To test the cochlear portion of the acoustic nerve, the nurse has the client close the
eyes and indicate when a ticking watch or rustling of the examiner’s fingertips is heard as the
stimulus is brought closer to the ear. To test the motor component of the trigeminal nerve, the
nurse asks the client to clench the teeth and palpates the masseter muscles just above the
mandibular angle. To test the sensory component of the trigeminal nerve (cranial nerve V), the
nurse has the client identify light and sharp touch on both sides of the face. Asking the client to
raise the eyebrows and watching for symmetry is one method of testing the function of the facial
nerve (cranial nerve VII).
1. 5.ID: 383732891
A nurse is preparing a female client for a rectal examination. Into which position does the nurse
assist the client?A. Supine
B. Standing
C. Lithotomy
D. Left lateral Correct
Rationale: A female client is placed in the left lateral position for a rectal examination. If the
examiner is examining the genitalia as well as the rectum, the woman is placed in the lithotomy
position. A male client is placed in the left lateral or standing position. It would be difficult to
perform a rectal examination on a client in the supine position.
TestTaking Strategy: Use the process of elimination and focus on the subject, a rectal
examination of a female client. Recalling that the left lateral position is used to administer an
enema will assist in directing you to the correct option. Review the procedure for performing a
rectal examination of a female client if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patientcentered
collaborative care (6th ed., p. 1651). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation
Content Area: Health Assessment/Physical Exam
Awarded 1.0 points out of 1.0 possible points.
2. 6.ID: 383733761
A nurse is preparing to listen to a client's breath sounds. The nurse should:A. Ask the client to lie down
B. Listen to the right lung, then the left lung
C. Ask the client to take shallow rapid breaths through the mouth
D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest
Correct
Rationale: The nurse asks the client to sit and lean forward slightly, with the arms resting
comfortably across the lap. The client is asked to breathe through the mouth a little more deeply
than usual but is told to stop if he or she begins to feel dizzy. The nurse uses the flat diaphragm
endpiece of the stethoscope, holding it firmly on the chest wall, and listens for at least one full
respiration in each location, moving from side to side to compare sounds.
TestTaking Strategy: Use the process of elimination. The fact that it would be difficult to listen to
breath sounds if the client were lying down will assist you in eliminating this option. Next
eliminate the option containing the word “rapid.” To select from the remaining options, visualize
the procedure and recall that sidetoside comparison is important in the assessment of breath
sounds. Review respiratory assessment procedures if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patientcentered
collaborative care (6th ed., p. 561). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Awarded 1.0 points out of 1.0 possible points.
3. 7.ID: 383734529A clinic nurse about to meet a new client plans to gather subjective data regarding the client's
health history. Which of the following actions does the nurse take to help ensure the success of
the interview? Select all that apply.
A. Ensuring that the room is private Correct
B. Seeing that distracting objects are removed from the room Correct
C. Having the client sit across a desk or table to give the client some personal
space
D. Maintaining a distance of 2 feet or closer between the nurse and client
E. Switching on a dim light that will make the room cozier and help the client relax
Rationale: The physical environment of an interview room should provide optimal conditions to
encourage a smooth interview and make the client feel comfortable. The nurse ensures that
privacy is maintained, that there are no interruptions during the interview, that the room
temperature is comfortable, that lighting is sufficient, that ambient noise is reduced, and that
distracting objects are removed from the room. The nurse also ensures that the client and nurse
are seated comfortably, eye to eye, without a desk or table between them, because a desk or
table would act as a barrier. The nurse should maintain a distance of 4 to 5 feet from the client to
avoid invading the client’s private space, which might create anxiety on the part of the client.
TestTaking Strategy: Use the process of elimination. Eliminate the options that are comparable
or alike and involves personal space (2 feet or closer and the client sits across a desk or table).
To select from the remaining options, recall that adequate lighting is important for the nurse to
observe the client during the interview and a private room without distractions is important.
Review the physical environment and its effect on a client interview if you had difficulty with this
question.
References: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 57). St.
Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 236239). St. Louis: Mosby.Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Planning
Content Area: Health Assessment/Physical Exam
Awarded 1.0 points out of 1.0 possible points.
4. 8.ID: 383733788
A nurse performing a neurological assessment is preparing to assess the optic nerve. The nurse
performs this examination by:
A. Assessing visual acuity Correct
B. Inspecting the eyelids for ptosis
C. Assessing pupil constriction
D. Assessing ocular movements
Rationale: The optic nerve is assessed through the testing of visual acuity and visual fields by
means of confrontation. Ptosis, a drooping of the eyelid, can be assessed by means of
inspection of the eyelids. Testing of the abducens, oculomotor, and trochlear nerves, which are
usually assessed together, involves checking the pupils for size, regularity, equality, direct and
consensual light reaction, and accommodation and assessing extraocular movements through
the cardinal positions of gaze.
9.ID: 383732838
A nurse is preparing to screen a client’s vision with the use of a Snellen chart. The nurse:E. Tests the right eye, then tests the left eye, and finally tests both eyes together
Correct
F. Assesses both eyes together, then assesses the right and left eyes separately
G. Asks the client to stand 40 feet from the chart and read the largest line on the
chart
H. Asks the client to stand 40 feet from the chart and read the line that can be read
200 feet away by someone with unimpaired vision
Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a
welllit spot with the chart at the client’s eye level. The client is positioned on a mark exactly 20
feet from the chart. The client uses an opaque card to shield one eye at a time during the test;
after each eye is tested, both eyes are assessed together. The client is asked to read through
the chart to the smallest line of letters he or she can discern. The client is encouraged to read
the next smallest line as well. Therefore the other options are incorrect.
10.ID: 383732872
A nurse is preparing to listen to the breath sounds of a client. The nurse should:
I. Ask the client to lie prone
J. Ask the client to breathe in and out through the nose
K. Hold the bell of the stethoscope lightly against the chestL. Listen for at least one full respiration in each location on the chest Correct
Rationale: To best listen to breathe sounds, the nurse asks the client to sit, leaning slightly
forward, with the arms resting comfortably across the lap. The client is instructed to breathe
through the mouth, a little deeper than usual, but to stop if he or she feels dizzy. The flat
diaphragm endpiece of the stethoscope is held firmly against the client’s chest wall. The nurse
listens for at least one full respiration in each location on the chest. Sidetoside comparison is
most important in the assessment of breath sounds.
11.ID: 383733780
During a physical assessment, the client tells the nurse that he is having difficulty swallowing
medications and food. The nurse gathers additional subjective data and documents that the
client is experiencing: [Show Less]