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  • While collecting a client's urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia?
  • A pulse strength of 3+ is described as which term?
  • Pain described as arising from internal organs such as the abdomen is best categorized as which type?
  • After a home assessment of an older adult fall risk, which intervention would the nurse suggest?
  • Which term describes inflammation around the nail base?
  • Which action is important for establishing good communication with a client who has impaired hearing?
  • Which nursing intervention would the nurse use to encourage the client to verbalize their personal health problem?
  • During a Romberg test, where should the nurse position themselves in relation to the client?
  • Which infant has an abnormal weight?Four infants are being assessed: Infant 1 weighs 6 lb 8 oz, Infant 2 weighs 4 lb 2 oz, Infant 3 weighs 7 lb 8 oz, Infant 4 weighs 8 lb 3 oz.
  • Damage to which nerve would cause the inability to move the eyes laterally?
  • A circumscribed elevation of the skin, 0.6 cm in diameter, filled with serous fluid on the cheek is most accurately documented as which term?
  • For a pelvic examination during a health checkup, which position should the client be prepared for?
  • A client develops allergic reaction during physical assessment. Which nurse statement indicates a lack of understanding?
  • When assessing an older client as they walk into the exam room, which finding would the nurse document as abnormal?
  • A client who does not understand English requires an interpreter. Which action may exacerbate health disparities?
  • When interpreting findings from a pain assessment, which factors would the nurse consider the most significant influences on a client's perception of pain?
  • The condition where the eyes do not focus on a single object simultaneously and appear crossed is most accurately called what?
  • When assessing clients with gastrointestinal problems, which client would the nurse suspect has shigellosis?
  • Which sign is commonly associated with fever?
  • Arcus senilis is most commonly observed in which population?
  • The nurse just arrived on the unit for his shift. Which action would the nurse take first to collect an initial set of data about the clients assigned to the nurses care?
  • When a new nurse develops pulse assessment plans for multiple clients, which client's plan correctly yields effective results?
  • During a physical assessment of a female client in a left lateral recumbent position, which body system would the nurse assess?
  • Upon entering the exam room of a client and spouse, the client appears withdrawn and fearful of the spouse. What action should the nurse take?
  • For which age group would the nurse expect the occurrence of chronic illness to be the highest?
  • For a client arriving for an appointment, which action would be beneficial during the assessment interview?
  • Arrange the steps of the bimanual deep palpation technique in sequence:
  • Which statement best describes nursing diagnoses as distinct from medical diagnoses?
  • A bluish coloration of the skin during assessment would most likely lead the nurse to suspect which condition?
  • Which finding during a wound assessment would most likely require gloves and a gown as part of protective precautions?
  • A swollen area in front of the ear in a patient with ear pain most likely involves which lymph node?
  • Which factor appears to influence the client's health practices?
  • Which action would the nurse take when a client is receiving total parenteral nutrition?
  • Long-term marijuana use is associated with an increased risk of which health condition?
  • During an interview with an older adult following a stroke, which approach supports confidentiality when family asks for access to records?
  • The nurse, after a cardiac catheterization, notes the client's skin at the site is cool, tender to touch, with edema. Which condition would the nurse suspect?
  • A client reports sleeping until noon every day and taking frequent naps during the rest of the day. Initially which action would the nurse take?
  • Which finding would necessitate holding gastrostomy feedings and meds and notifying HCP immediately?
  • In Weber test, if sound lateralizes to the unaffected ear, what type of hearing loss is suspected in the affected ear?
  • The chest with an AP diameter approximately equal to its transverse diameter is most commonly described as which chest shape seen in older adults?
  • After assessing several clients, which would indicate a need for parenteral nutrition?
  • What type of fever is characterized by fever spikes with a normal body temperature occurring at least once a day?
  • Which sequence correctly represents the order of the nursing process steps?
  • During a falls risk assessment, what action should the nurse take after learning the client recently fell?
  • The nurse providing primary preventive care at a community health care center focuses on which type of activity?
  • Paronychia is best described as inflammation around which part?
  • Which client’s findings indicate risk for heart disease?
  • Which nursing functional pattern focuses on self-concept and body image?
  • A patient’s BMI of 23.53 falls into which category?
  • Which question would be most appropriate to assess growth in a pediatric health history?
  • Which factor would lead the nurse to identify an illness as chronic?
  • A patient with a history of cardiac dysrhythmias is admitted with fluid volume deficit due to a pulmonary infection. The nurse records several vital signs. Which sign requires reassessment?
  • Which finding would prompt further assessment for nutritional risk?
  • When assessing a confused client upon room entry, which action should the nurse take?
  • Paronychia is best described as inflammation around the skin adjacent to which structure?
  • Which client would the nurse suspect has an increased risk of hyperlipidemia?
  • What is the highest risk factor for developing a deep vein thrombosis?
  • To screen for disease-related weight change, which question would you ask?
  • Which skin finding is described as increased visibility of oxyhemoglobin due to capillary dilation?
  • Which client scenario represents a health promotion nursing diagnosis?
  • When documenting care for a restrained patient, which item is essential to record?
  • For which involuntary physiologic response would the nurse monitor development in a client experiencing pain?
  • Which statement best reflects effective weight management education after BMI instruction?
  • For a client admitted with metabolic acidosis, which two body systems would the nurse assess for compensatory changes?
  • The nurse expects a client with an elevated temp to exhibit which indicator of pyrexia?
  • The nurse records temperatures for four febrile clients over four days. Which client demonstrates remittent fever?
  • Which type of interview would the nurse utilize when admitting a client to a clinic?
  • Which temperature measurement method is most accurate for core body temperature?
  • Which lymph node is located just anterior to the ear and commonly involved with ear infections?
  • The nurse documents data that was gathered during an assessment in a client's medical record. Which action would the nurse take to ensure that the data is meaningful to other health care providers?
  • Gastric lavage would be questioned for which clinical indicator?
  • Metabolic acidosis triggers compensatory changes in which two body systems?
  • Which temperature would the nurse associate with shivering uncontrollably and memory loss, depression, and poor judgment?
  • When a nurse reviews a new admit's forms and orders, which task should be a priority in the initial plan of care?
  • When preparing to assess a client with active tuberculosis, which piece of PPE should the nurse put on before entering the room?
  • Inflammation at the bases of the nails is most likely related to which event?
  • Which statement about total parenteral nutrition administration is correct?
  • Which statement best describes how fever is measured to assess core body temperature?
  • Which description matches coarse rhonchi that clear with coughing?
  • After abdominal surgery, which cue would the nurse use to form a data cluster?
  • Which Korotkoff sound represents the diastolic pressure for children?
  • The ratio of the anteroposterior diameter to the transverse diameter of the chest is 1:1. Which finding best supports this conclusion?
  • In which situation would the nurse consider family members as the primary source of information?
  • If the defining characteristics of a client's assessment data apply to more than one diagnosis, which action should the nurse take?
  • A client weighs 150 lb and is 5 ft 7 in tall. Which numerical value reflects this client's BMI?
  • After performing an optical assessment, a client has impaired near vision. Which finding would confirm presbyopia?
  • What term refers to inflammation of the skin at the base of the nail?
  • After presenting info about falls risk assessment to nursing staff, which participant statement needs review for corrective action?
  • Which physical change would the nurse observe in a client with malnutrition?
  • In a four-client ED triage, which client would be treated last?
  • A nurse documents a client's pulse as 3+. What does this indicate about pulse strength?
  • While assessing the nails of a client with diabetes, the nurse finds the skin on hands and feet dry due to infection. Which rationale would the nurse associate with this dryness?
  • In an older adult with dehydration, which finding would the nurse identify as an early sign?
  • In nursing diagnosis, which related factor would the nurse attach?
  • What is an appropriate initial step when preparing to palpate the abdomen using a two-handed deep technique?
  • A drug that causes pupillary dilation belongs to which category?
  • Remittent fever is best described as fever that:
  • While assessing a pediatric patient, an ophthalmologist notes inability to focus with both eyes. Which finding would confirm diagnosis of strabismus?
  • A client develops wheezing and hives within minutes of latex exposure. This reaction is most consistent with which hypersensitivity?
  • Pupillary dilation is commonly associated with which drug class?
  • Which statement describes a nursing process step involved in selecting a nursing diagnosis?
  • Which client would the nurse anticipate needing a referral to a support group for people with vision loss?
  • A client experiencing hypercarbia would exhibit which pattern of breathing?
  • In a patient with a chest tube drainage system, persistent absence of bubbling in the suction control chamber most likely indicates what?
  • Which assessment item needs to be documented on a client with restraints?
  • Which condition would the nurse suspect when a client reports itching two days after a physical exam?
  • During assessment of four clients, which client demonstrates Cheyne-stokes respiration?
  • If a client with heart disease develops digital cyanosis, which site should the nurse assess to confirm cyanosis?
  • The inflammation of the skin at the bases of the nails would most likely be associated with which event?
  • In the transtheoretical model of health behavior change, which stage describes a client who has not started walking 30 minutes daily and exercising five days a week?
  • Bilateral wheezing in the upper lung regions is most consistent with which pathophysiological process?
  • Based on the transtheoretical model, which stage would the nurse document for a client who has maintained the behavior for 8 months?
  • Which intervention is essential to prevent DVT in postoperative patients?
  • Obstruction to the outflow of aqueous humor; Which finding would support a diagnosis of glaucoma?
  • The nurse auscultates coarse rhonchi in the anterior upper lung fields bilaterally that clears with coughing. Which condition would the nurse associate with these sounds?
  • Which dental development question is appropriate to assess growth in pediatric health history?
  • A patient who has just had a falls risk assessment should have which action prioritized?
  • Presbyopia is best described as which of the following?
  • In the left lateral recumbent position, which body system is most appropriately examined?
  • Which reliable site would the nurse utilize to assess a client for jaundice?
  • Which term denotes a regular and slow respiratory rate?
  • Which term describes the exaggerated posterior curvature of the thoracic spine?
  • In the same visual field testing sequence, which step comes last?
  • When there is uncertainty about cuff size, what is the best action to ensure accurate blood pressure measurement?
  • In the wound care scenario, what action would most help prevent tetanus?
  • A patient with chest pain, shortness of breath, weakness, and vomiting; which site would the nurse check for a pulse?
  • A client shows enlarged lymph nodes and reports history of IV drug use and bisexual activity. Which diagnosis would the nurse suspect?
  • Which client would have a health promotion nursing diagnosis?
  • Which client profile represents the highest medical risk for coronary heart disease and hypertension?
  • A patient opens eyes to speech, verbal response is disoriented, and motor response localizes to pain. What is the GCS score?
  • Which step immediately follows asking the client to close the right eye gently in the described visual field assessment sequence?
  • When initiating an assessment interview, which action best demonstrates respect for the patient?
  • Which action best sets the stage for a client-centered interview?
  • When conducting an assessment of a client who does not speak English and an interpreter is unavailable, which action would the nurse not utilize?
  • An older adult who cannot see nearby objects most likely has which condition?
  • In evaluating cardiovascular risk, which client has the highest risk?
  • Which factor would the nurse assess for a client reporting constipation?
  • What respiratory rate would be expected for a 2-year-old child?
  • What is the proper sequential order of steps when assessing a lesion?
  • During an elderly checkup, signs of elder abuse are observed. Which physical finding would confirm the nurse's suspicion?
  • Which position would be contraindicated for a client with chronic obstructive respiratory disease?
  • Which UAP statement reflects effective learning about sites for assessing body temperature?
  • When obtaining a health history, which question would the nurse most appropriately ask?
  • Which finding most clearly signals dehydration in a patient with three days of vomiting and diarrhea?
  • Which condition is indicated by a thin white ring around the margin of the iris in an older adult?
  • Which statement best describes kyphosis?
  • During orientation, an RN reviews content about the third heart sound S3. Which statement indicates ineffective learning?
  • Based on current research, when asked about spanking as a disciplinary technique, which response would the nurse utilize?
  • Which term describes aging-related loss of near vision?
  • Which nursing action would increase the effectiveness of teaching a client to self-inject insulin?
  • A client with heat stroke has a measured temperature of 39°C. What temperature in Fahrenheit should be documented?
  • When assessing a patient for malnutrition the nurse would monitor for increase in liver enzymes and a decrease in which water soluble vitamin?
  • Which factor would the nurse associate with dry skin in the context of skin assessment?
  • Which home modification best reduces fall risk for an older adult?
  • During a physical assessment, patchy areas with pigmentation loss on the skin, hands, and arms are observed. With which probable cause would the nurse associate this finding?
  • After teaching a male client about measures to maintain sexual health and prevent transmission of STI, which statement indicates effective learning?
  • During a thorough assessment to identify the cause of a client’s anxiety, which critical thinking attitude is involved?
  • After teaching measures to protect against food-borne illness, which client statement reflects ineffective learning?
  • Which term describes an exaggerated posterior curvature of the thoracic spine?
  • Which part of the body would the nurse assess to confirm a diagnosis of frostbite?
  • Which route is used to measure core body temperature most accurately in adults?
  • In primary prevention, the nurse's focus is on what type of activity?
  • Based on provided data, which client would nurse suspect of having hypertension?
  • While assessing a client's vascular system, the nurse finds a diminished and barely capable pulse strength. Which documentation would the nurse utilize?
  • Post pelvic surgery, majority of pulmonary emboli begin as DVT in which area?
  • After STI prevention education, which statement indicates effective learning?
  • After teaching an obese client how to calculate the body mass index, which statement indicates effective learning?
  • Which measurement is used to determine the size of a lesion?
  • Which clinical indicator is most commonly used to determine whether a patient has a fluid deficit when the patient has three days of vomiting and diarrhea?
  • Which term describes the elasticity of the skin?
  • If a nurse observes a pulse deficit during a physical assessment, which pulses would be used to assess the pulse deficit?
  • What is the most appropriate description of a pulse that is not detectable?
  • Which site would be safer and less expensive for temperature measurement of a human?
  • Which site for temperature measurement is most cost-effective and safe in general practice?
  • Which assessment finding would prompt a nurse to wear a protective gown?
  • Which term would describe a small blister containing clear fluid?
  • When assessing LOC, which one of the four clients would the nurse identify as having the lowest neurological function?
  • A recent immigrant from China is critically ill and dying. To address emotional needs, which question would the nurse ask when collecting information?
  • Which statement indicates understanding of teaching about lice control?
  • Which physical skin finding would the nurse associate with opioid abuse?
  • During pulse assessment, the RN asks the student to check the apical pulse after assessing the radial pulse. What is the rationale for this request?
  • An assessment of an 89-year-old client with a history of severe congenital spinal deformity describes which condition?
  • Which symptom is a potential result of anticholinergic medication?
  • Which priority assessment would the nurse include when caring for a client who is experiencing depression?
  • Which factor would elevate a client’s oxygen saturation reading?
  • Which action is appropriate to avoid health disparities when communicating with someone who has limited English proficiency?
  • A adolescent is brought to the ED after stepping on a nail. The nurse asks about tetanus vaccination; the patient says all immunizations are up to date. A few days later the patient is admitted with tetanus. Which statement best describes the nurse's responsibility in this situation?
  • A client with renal failure states illness is a punishment for sins. Which cultural health belief is the client communicating?
  • Which statement indicates a risk of breast cancer?
  • Which cranial nerve is assessed when asking the client to shrug their shoulders and to turn their head against passive resistance?
  • During a physical examination, which assessment would the nurse anticipate when a client is placed in the lithotomy position?
  • Which is a benefit of using standard, formal nursing diagnostic statements?
  • Which statement indicates effective learning about measures to promote health?
  • Which factor can cause a pulse oximeter reading to falsely appear elevated, potentially masking hypoxemia?
  • Which item would be considered biographical data in a health history?
  • Which piece of information obtained during a client's health history would be classified as biographical information?
  • To evaluate the function of the extraocular muscles, which task would you perform?
  • Which transmission focus must be prevented when caring for a client with Hepatitis A?
  • In assessing a client's skin, which factor would most likely contribute to dry skin?
  • In a client with enlarged lymph nodes and a history of intravenous drug use, which diagnosis would the nurse suspect?
  • Which statement demonstrates proper food safety practice?
  • When preparing to assess a client with Clostridium difficile infection, which piece of PPE should the nurse put on before entering the room?
  • Cheyne-stokes respiration is described as alternating periods of what pattern?
  • Which potential cause would the nurse associate with eyes not focusing on an object simultaneously and appearing crossed?
  • Which body area is most commonly observed first to detect jaundice?
  • The Allen test assesses collateral circulation in which artery?
  • Which client would experience impaired near vision?
  • During range-of-motion assessment, the nurse explains adduction to the UAP. Which statement indicates effective learning?
  • Which sensory-related change is commonly seen in aging and can influence safety in daily activities?
  • When assessing an older adult male client, which clinical finding would the nurse expect as a response to the aging process?
  • A deficit in which action would indicate impairment of the cranial nerve XI?
  • In the emergency department, an unconscious patient who has severe bleeding from a motor vehicle crash is in hypovolemic shock. At which pulse site should the nurse obtain the pulse rate?
  • Which documentation practice best enhances clarity for other providers?
  • A nurse notes a patient with pneumonia has a history of diabetes. Which assessment would be most informative for monitoring infection control?
  • In strabismus assessment, which finding would support diagnosis aside from misalignment?
  • Arrange the sequence of events occurring during a fever in chronological order.
  • Corneal arcus is most strongly associated with increased risk of which condition?
  • Which statement indicates the client's interview is coming to a close?
  • The RN measures a client's BP as 130/80, while the UAP's measurement is 120/90. Which rationale would explain the measurement difference?
  • After conducting a falls risk assessment education session for the staff and observing falls risk assessments on the unit, which staff action needs review for corrective action?
  • Which feature distinguishes nursing diagnoses from medical diagnoses?
  • After reviewing otoscope use for assessment of the ear with the nursing staff, which participant response reflects safe follow up care for earwax near the tympanic membrane?
  • Which position would the nurse utilize to assess the musculoskeletal system, but contraindicated for clients experiencing chronic obstructive respiratory disease?
  • For an older adult admitted after a stroke, how should the nurse respond when the client's cousin asks to see the client's health record?
  • During fever resolution, what happens to pyrogens?
  • During blood pressure measurement, which error will most likely produce a false high diastolic reading?
  • In a knee replacement patient, which of the following is an example of subjective data?
  • Which data collection item is used to confirm assessment data?
  • When assessing a client with Hepatitis A, which substance must the nurse be especially careful to prevent transmitting?
  • Health disparities can be introduced when care is delivered by a staff member who does what?
  • Which step would the nurse take first when preparing a concept map for as assigned client?
  • A client reports right ear hearing loss. When performing a Weber test, the client hears the sound better with the right ear. Which condition would the nurse suspect?
  • Which temperature site is described as the preferred method for measuring body temperature in unconscious clients?
  • On admission, what sequence reflects proper initial assessment planning?
  • Which practice most effectively encourages a client to discuss personal health concerns during an interview?
  • A slight convex curve at the nail angle where the nail meets the skin, measuring about 160 degrees, is most appropriately described as which finding?
  • Ten days after abdominal surgery, a patient reports abdominal pain. This pain is best categorized as which type?
  • In which sequential order would the nurse assess the visual field of a client?
  • Gastric lavage should be questioned if which lab value is elevated?
  • A client with a blood pressure of 130/80 mmHg would most likely be advised to follow up with the primary care provider in which timeframe?
  • When would the nurse observe a client to assess their level of functioning?
  • Which nursing diagnosis would be most helpful in guiding the right nursing intervention for a client who is not aware of perineal care and has impaired skin integrity?
  • Postoperative care for a client who had surgery to repair a deviated septum: which complication should the nurse monitor for?
  • The Glasgow Coma Scale scoring scenario: a patient is alert and opens eyes to sound or conversation, speaks confusedly, and obeys commands. What is the approximate score?
  • Which functional pattern addresses coping with altered body image in a patient undergoing chemotherapy?
  • An older client with chills and fever; which rectal temperature reading would the nurse anticipate?
  • When a client asks about tetanus antitoxin, which immunologic benefit does it provide?
  • Which temperature range indicates moderate hypothermia?
  • A patient has pupillary dilation; which drug would most likely cause this effect?
  • Which client is at a high risk for a rise in blood pressure based on common risk factors (age and obesity)?
  • Patchy depigmentation of the skin in localized areas is most commonly associated with which type of disorder?
  • Which of the following would indicate a person is in the initial phase of fever development?
  • To prevent heatstroke, a client on diuretic therapy should avoid which activity?
  • A client has a tuberculin skin test showing a 7 mm induration. Which statement best describes this result?
  • Which assessment test differentiates conduction from sensorineural hearing loss?
  • What is the first step in the described sequence for assessing a client's visual field?
  • After assessing a client's muscle functionality, the nurse assigns a Lovett scale grade of F. Which statement best describes the muscle functionality?
  • Which of the following is a key consideration when interpreting a TB skin test result in a patient at risk for infection?
  • In a client with diarrhea, which clinical indicator would the nurse anticipate decreasing?
  • In a client with a closed chest tube drainage system connected to suction, which finding requires additional evaluation?
  • When assessing a client's blood pressure, obtained via the unsupported left arm, which reading error would the nurse expect?
  • Which drug would be most likely to cause mydriasis?
  • Which action should the nurse take if a gastrostomy feeding patient coughs during administration?
  • When assessing a client who had a thyroidectomy yesterday, which cue would the nurse associate with an initial sign of hypocalcemia?
  • A client reports difficulty breathing and the nurse auscultates bilateral wheezing in the anterior upper lobes. Which rationale would explain this sound?
  • What is the approximate normal angle between the nail bed and the nail plate, around 160 degrees?
  • When gathering data for a clients health history, which intellectual factor would the nurse consider as a dimension?
  • During a Romberg test, what is the correct nurse position relative to the client?
  • During a general checkup of four female clients, which client is most at risk of developing breast cancer?
  • A patient weighed 210 pounds on admission and after two days of diuretic therapy weighs 205 pounds. Which value best represents the liters of fluid excreted?
  • Which long-term effect would the nurse associate with marijuana use?
  • Which question best helps identify whether diabetes may contribute to pneumonia risk in a patient?
  • Which statement describes the cultural health belief that illness is caused by supernatural forces?
  • To ensure breast health, the nurse teaches a client about prevention and detection practices. Which client statement indicates the need for further teaching?
  • Paresthesias are most closely associated with which postoperative electrolyte disturbance after thyroidectomy?
  • Which condition involves redness and swelling around the nail folds?
  • Which of the following is a normal blood pressure for a 12-year-old?
  • Which assessment finding most strongly indicates risk for heart disease?
  • Which pulse site would the nurse use to perform the Allen test?
  • When interviewing and assessing a 17 year old client, which finding alters the nurse to explore substance abuse with the adolescent?
  • In a group of four clients, which is identified as at risk for breast cancer?
  • Which lab parameter is commonly monitored closely in patients on total parenteral nutrition?
  • The nurse uses a thermometer to obtain the client's temperature when the forehead is warm. This action is called what?
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