NCLEX 4000 Questions with Answers Health Assessment
A nurse determines that a client has 20/40 vision. Which statement about this clients vision is
... [Show More] true?
a) the client can read the entire vision chart at a distance of 40'
b) the client can read from a distance of 20' what a person with normal vision can read at 40'
c) the client can read the vision chart from a distance of 20' with the right eye and from 40' with the left eye
d) the client can read at a distance of 30' what a person can read at a distance of 40' Correct Answer B) the client can read from a distance of 20' what a person with normal vision can read at 40'
the smaller the denominator the worse the vision
the numerator is always 20, the distance in feet between the chart and person
the denominator indicates what distance normal vision can read the chart
location of aortic stenosis Correct Answer 2nd intercostal R
When assessing a clients abdomen which finding should the nurse report as abmormal
a) dullness over the liver
b) bowel sounds occuring every 10 seconds
c) shifting dullness over the abdomen
d) vascular sound over the renal arteries Correct Answer c) shifting dullness over the abdomen would indicate ascites which is abnormal
dullness over the liver, bowel sounds every 10 seconds and vascular sounds over the renal arteries are all normal sounds in the abdomen
A nurse is assesing a 47 year old client who has come to the clinic for his annual physical. One of the first physical signs of aging is
a) having more frequent aches and pains
b) failing eyesight, especially close vision
c) increasing loss of muscle tone
d) accepting limitations while developing assets Correct Answer b) failing eyesight, especially close vision is one of the first signs of aging in middle life
more frequent aches and pains occur around age 65
loss of muscle tone increases around age 80
accepting limitations while developing assets occurs around age 31-45
A nurse is assessing a clients pulse. Which pulse feature should the nurse document?
a) timing in the cycle
b) amplitude
c) pitch
d) intensity Correct Answer B) amplitude
(ARR)
Amplitude, Rate, Rhythm
When ausculating a clients abdomen, a nurse detects high pitched gurgles over the lower Right quadrant. Based on this finding,m the nurse suspects
a) decreased bowel motility
b) increased bowel motility
c) nothing abnormal
d) abdominal cramping Correct Answer c) nothing abnormal
high pitch gurgles are normal findings
While performing an abdominal assessment a nurse should follow which examination sequence
a) inspection, ausculation, percussion, palpation
b) inspection, ausculation, palpation, percussion
c) inspection, percussion, palpation, ausculation
d) inspection, palpation, percussion, ausculation Correct Answer a) inspection, ausculation, percussion, palpation
all other sequencing would be inspection, palpation, percussion and then ausculation [Show Less]