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

Bank
Chapter 19
Question 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
3. A focused assessment at the end of the shift
4. A complete physical examination
Correct Answer: 3
Rationale 1: The LPN/LVN most often will be responsible for a focused assessment on the client once or twice a
shift. The LPN/LVN may be asked to conduct a focused assessment of a body part, but, in this case, it would be of
the client's lungs, as the client has pneumonia. A head-to-toe assessment, complete physical examination, or
admission assessment is generally conducted by the RN with data-collection assistance from the LPN/LVN.
Rationale 2: The LPN/LVN most often will be responsible for a focused assessment on the client once or twice a
shift. The LPN/LVN may be asked to conduct a focused assessment of a body part, but, in this case, it would be of
the client's lungs, as the client has pneumonia. A head-to-toe assessment, complete physical examination, or
admission assessment is generally conducted by the RN with data-collection assistance from the LPN/LVN.
Rationale 3: The LPN/LVN most often will be responsible for a focused assessment on the client once or twice a
shift. The LPN/LVN may be asked to conduct a focused assessment of a body part, but, in this case, it would be of
the client's lungs, as the client has pneumonia. A head-to-toe assessment, complete physical examination, or
admission assessment is generally conducted by the RN with data-collection assistance from the LPN/LVN.
Rationale 4: The LPN/LVN most often will be responsible for a focused assessment on the client once or twice a
shift. The LPN/LVN may be asked to conduct a focused assessment of a body part, but, in this case, it would be of
the client's lungs, as the client has pneumonia. A head-to-toe assessment, complete physical examination, or
admission assessment is generally conducted by the RN with data-collection assistance from the LPN/LVN.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Learning Outcome: Name three types of physical health assessment and discuss the role of the LPN/LVN in
health assessment.
Question 2
Type: MCMA
The LPN/LVN assists with admitting a client with severe gastric pain by doing which of the following? Select all
that apply.
Standard Text: Select all that apply.
1. Measuring vital signs
2. Determining the client's current pain level
3. Performing a head-to-toe complete admission assessment
4. Asking the client about allergies
5. Administering analgesics as ordered
Correct Answer: 1,2,4,5
Rationale 1: The LPN/LVN may perform all of the tasks except the complete assessment, which is the
responsibility of the RN.
Rationale 2: The LPN/LVN may perform all of the tasks except the complete assessment, which is the
responsibility of the RN.
Rationale 3: The LPN/LVN may perform all of the tasks except the complete assessment, which is the
responsibility of the RN.
Rationale 4: The LPN/LVN may perform all of the tasks except the complete assessment, which is the
responsibility of the RN.
Rationale 5: The LPN/LVN may perform all of the tasks except the complete assessment, which is the
responsibility of the RN.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Name three types of physical health assessment and discuss the role of the LPN/LVN in
health assessment.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Question 3
Type: MCMA
The nurse conducts a focused neurological assessment of the client with a seizure disorder by doing which of the
following? .Select all that apply.
Standard Text: Select all that apply.
1. Assessing pupils for accommodation and response to light
2. Assessing general mental status
3. Checking grip strength bilaterally
4. Assessing pain status
5. Measuring visual acuity
Correct Answer: 1,2,3
Rationale 1: Mental status, pupil response, and grip strength all would be part of a focused neurological
examination. Pain and visual acuity assessments would not be part of the exam unless the client had another
problem that would affect vision or need pain assessment.
Rationale 2: Mental status, pupil response, and grip strength all would be part of a focused neurological
examination. Pain and visual acuity assessments would not be part of the exam unless the client had another
problem that would affect vision or need pain assessment.
Rationale 3: Mental status, pupil response, and grip strength all would be part of a focused neurological
examination. Pain and visual acuity assessments would not be part of the exam unless the client had another
problem that would affect vision or need pain assessment.
Rationale 4: Mental status, pupil response, and grip strength all would be part of a focused neurological
examination. Pain and visual acuity assessments would not be part of the exam unless the client had another
problem that would affect vision or need pain assessment.
Rationale 5: Mental status, pupil response, and grip strength all would be part of a focused neurological
examination. Pain and visual acuity assessments would not be part of the exam unless the client had another
problem that would affect vision or need pain assessment.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify elements to check by body system.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Question 4
Type: MCSA
While performing a focused assessment on the client, the nurse notes a skin rash, which the nurse correctly
documents as:
1. Rash on face, arms, and trunk.
2. Maculopapular rash over trunk that client says itches.
3. 2cm boil noted on the client's shoulder.
4. Erythematous butterfly-shaped rash noted over the client's cheeks and nose.
Correct Answer: 4
Rationale 1: The student describes the color, size, shape, and location of the butterfly rash, which is correct. Rash
on face, arms, and trunk does not include shape, color, or any other properties. The boil on the shoulder gives the
size but not the color or presence of drainage or discomfort. Maculopapular rash on the trunk is not specific
enough in location, and does not describe the color or size. Documentation of assessment findings should be done
in such a way that the reader can "see" the finding even if he hasn't yet seen the client.
Rationale 2: The student describes the color, size, shape, and location of the butterfly rash, which is correct. Rash
on face, arms, and trunk does not include shape, color, or any other properties. The boil on the shoulder gives the
size but not the color or presence of drainage or discomfort. Maculopapular rash on the trunk is not specific
enough in location, and does not describe the color or size. Documentation of assessment findings should be done
in such a way that the reader can "see" the finding even if he hasn't yet seen the client.
Rationale 3: The student describes the color, size, shape, and location of the butterfly rash, which is correct. Rash
on face, arms, and trunk does not include shape, color, or any other properties. The boil on the shoulder gives the
size but not the color or presence of drainage or discomfort. Maculopapular rash on the trunk is not specific
enough in location, and does not describe the color or size. Documentation of assessment findings should be done
in such a way that the reader can "see" the finding even if he hasn't yet seen the client.
Rationale 4: The student describes the color, size, shape, and location of the butterfly rash, which is correct. Rash
on face, arms, and trunk does not include shape, color, or any other properties. The boil on the shoulder gives the
size but not the color or presence of drainage or discomfort. Maculopapular rash on the trunk is not specific
enough in location, and does not describe the color or size. Documentation of assessment findings should be done
in such a way that the reader can "see" the finding even if he hasn't yet seen the client.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Learning Outcome: Identify elements to check by body system.


Question 5
Type: MCMA
The nurse conducts a focused assessment of a client's peripheral vascular system including which of the
following?
Standard Text: Select all that apply.
1. Vital signs
2. Perfusion
3. Capillary refill time
4. Skin color of extremities
5. Skin turgor
Correct Answer: 1,2,3,4
Rationale 1: Assessment of the peripheral vascular system includes color, pulses, blood pressure, and capillary
refill time, but does not normally include skin turgor, as this is a test for hydration.
Rationale 2: Assessment of the peripheral vascular system includes color, pulses, blood pressure, and capillary
refill time, but does not normally include skin turgor, as this is a test for hydration.
Rationale 3: Assessment of the peripheral vascular system includes color, pulses, blood pressure, and capillary
refill time, but does not normally include skin turgor, as this is a test for hydration.
Rationale 4: Assessment of the peripheral vascular system includes color, pulses, blood pressure, and capillary
refill time, but does not normally include skin turgor, as this is a test for hydration.
Rationale 5: Assessment of the peripheral vascular system includes color, pulses, blood pressure, and capillary
refill time, but does not normally include skin turgor, as this is a test for hydration.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify elements to check by body system.
Question 6
Type: MCSA
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

The nurse preparing to auscultate the apical heart rate on the client having an annual physical examination would
do what first?
1. Document client response.
2. Remove the cover sheet from the client.
3. Warm the bell of the stethoscope.
4. Observe respiratory effort.
Correct Answer: 3
Rationale 1: The nurse would use the bell of the stethoscope, warmed in the hand for client comfort. The drape
need only be removed enough to bare the apical area of the chest. Respiratory effort would be performed when
assessing respiratory rate, and documentation would be done after auscultating heart rate.
Rationale 2: The nurse would use the bell of the stethoscope, warmed in the hand for client comfort. The drape
need only be removed enough to bare the apical area of the chest. Respiratory effort would be performed when
assessing respiratory rate, and documentation would be done after auscultating heart rate.
Rationale 3: The nurse would use the bell of the stethoscope, warmed in the hand for client comfort. The drape
need only be removed enough to bare the apical area of the chest. Respiratory effort would be performed when
assessing respiratory rate, and documentation would be done after auscultating heart rate.
Rationale 4: The nurse would use the bell of the stethoscope, warmed in the hand for client comfort. The drape
need only be removed enough to bare the apical area of the chest. Respiratory effort would be performed when
assessing respiratory rate, and documentation would be done after auscultating heart rate.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Discuss preparation of client and environment for examination.
Question 7
Type: MCSA
When preparing the room for an elderly client coming to the provider's office for her annual physical examination,
the nurse would do which of the following?
1. Turn the heat to 80F.
2. Provide blankets for warmth.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

3. Turn all the bright lights on.


4. Place towels on the floor.
Correct Answer: 2
Rationale 1: The nurse prepares the room by making sure all necessary equipment is available and then puts
blankets in the room in case the client becomes chilled while waiting for physician to arrive. 80F would be an
excessive temperature, making other clients uncomfortable. Bright lights would not be turned on until the
physician arrives to perform the exam, and towels on the floor would increase the risk of the client's slipping.
Rationale 2: The nurse prepares the room by making sure all necessary equipment is available and then puts
blankets in the room in case the client becomes chilled while waiting for physician to arrive. 80F would be an
excessive temperature, making other clients uncomfortable. Bright lights would not be turned on until the
physician arrives to perform the exam, and towels on the floor would increase the risk of the client's slipping.
Rationale 3: The nurse prepares the room by making sure all necessary equipment is available and then puts
blankets in the room in case the client becomes chilled while waiting for physician to arrive. 80F would be an
excessive temperature, making other clients uncomfortable. Bright lights would not be turned on until the
physician arrives to perform the exam, and towels on the floor would increase the risk of the client's slipping.
Rationale 4: The nurse prepares the room by making sure all necessary equipment is available and then puts
blankets in the room in case the client becomes chilled while waiting for physician to arrive. 80F would be an
excessive temperature, making other clients uncomfortable. Bright lights would not be turned on until the
physician arrives to perform the exam, and towels on the floor would increase the risk of the client's slipping.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Discuss preparation of client and environment for examination.
Question 8
Type: MCSA
When assessing the skin of a 75-year-old client the nurse identifies which of the following as a normal finding?
1. Pallor of the skin in the skinfolds of the axillae
2. Dry oral mucosa
3. Clubbing of the fingernails
4. Confusion and disorientation
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Correct Answer: 2
Rationale 1: Reduced production of saliva is part of the normal aging process, and is manifested by dry oral
mucosa. The elderly client should not have pallor, clubbing of the fingernails, or confusion as a normal result of
the aging process
Rationale 2: Reduced production of saliva is part of the normal aging process, and is manifested by dry oral
mucosa. The elderly client should not have pallor, clubbing of the fingernails, or confusion as a normal result of
the aging process
Rationale 3: Reduced production of saliva is part of the normal aging process, and is manifested by dry oral
mucosa. The elderly client should not have pallor, clubbing of the fingernails, or confusion as a normal result of
the aging process
Rationale 4: Reduced production of saliva is part of the normal aging process, and is manifested by dry oral
mucosa. The elderly client should not have pallor, clubbing of the fingernails, or confusion as a normal result of
the aging process
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify potential variables in data by age or condition.
Question 9
Type: MCSA
Which of the following would not be included when the graduate LPN/LVN conducts a focused assessment of the
client's lungs?
1. Observe the chest as the client breathes.
2. Gently palpate the upper chest for crepitus.
3. Percuss the airways.
4. Auscultate for adventitious breath sounds.
Correct Answer: 3
Rationale 1: Percussion is a method of examination that the entry-level LPN/LVN does not perform. With
training, the LPN/LVN may perform this method later in practice. Observing, palpating, and auscultating would
all be expectations of a focused examination of the lungs.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 2: Percussion is a method of examination that the entry-level LPN/LVN does not perform. With
training, the LPN/LVN may perform this method later in practice. Observing, palpating, and auscultating would
all be expectations of a focused examination of the lungs.
Rationale 3: Percussion is a method of examination that the entry-level LPN/LVN does not perform. With
training, the LPN/LVN may perform this method later in practice. Observing, palpating, and auscultating would
all be expectations of a focused examination of the lungs.
Rationale 4: Percussion is a method of examination that the entry-level LPN/LVN does not perform. With
training, the LPN/LVN may perform this method later in practice. Observing, palpating, and auscultating would
all be expectations of a focused examination of the lungs.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Name four methods of examination and state which are commonly used by LPNs/LVNs.
Question 10
Type: MCSA
The nurse is preparing to perform a focused assessment, using inspection, of a 10-year-old client admitted with
asthma. The nurse is aware that a quiet environment is best for the assessment for which of the following reasons?
1. The client might be bothered by noise and have another attack.
2. Hearing audible wheezes is an important part of inspection.
3. The child's blood pressure will rise in a noisy environment.
4. The client will not be able to hear the nurse's questions.
Correct Answer: 2
Rationale 1: The senses of hearing and smell are important aspects of inspection. The nurse would need to be
able to hear inspiratory or expiratory wheezes of the child. The child's blood pressure will not likely be affected
by noise at this age, and noise would not contribute to another asthma attack. Most children hear relatively well in
a noisy environment.
Rationale 2: The senses of hearing and smell are important aspects of inspection. The nurse would need to be
able to hear inspiratory or expiratory wheezes of the child. The child's blood pressure will not likely be affected
by noise at this age, and noise would not contribute to another asthma attack. Most children hear relatively well in
a noisy environment.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 3: The senses of hearing and smell are important aspects of inspection. The nurse would need to be
able to hear inspiratory or expiratory wheezes of the child. The child's blood pressure will not likely be affected
by noise at this age, and noise would not contribute to another asthma attack. Most children hear relatively well in
a noisy environment.
Rationale 4: The senses of hearing and smell are important aspects of inspection. The nurse would need to be
able to hear inspiratory or expiratory wheezes of the child. The child's blood pressure will not likely be affected
by noise at this age, and noise would not contribute to another asthma attack. Most children hear relatively well in
a noisy environment.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Name four methods of examination and state which are commonly used by LPNs/LVNs.
Question 11
Type: MCSA
The nurse assesses the superior ventral and dorsal left lateral aspect of the body, and correctly documents which of
the following?
1. Active bowel sounds in all four quadrants
2. Client complains of headache located near the forehead.
3. Breath sounds diminished in the left with rales noted.
4. Lower abdomen tender to the touch and slightly distended
Correct Answer: 3
Rationale 1: The superior aspect would be above the waist. Ventral and dorsal surfaces include the front and back
of the body. Superior left lateral would be the left chest, or breath sounds. The stomach is on the superior plane,
but is generally not assessed by the nurse dorsally. The headache is in the cranial cavity. Abdominal problems
would be described as inferior, ventral, and either right or left upper or lower quadrants.
Rationale 2: The superior aspect would be above the waist. Ventral and dorsal surfaces include the front and back
of the body. Superior left lateral would be the left chest, or breath sounds. The stomach is on the superior plane,
but is generally not assessed by the nurse dorsally. The headache is in the cranial cavity. Abdominal problems
would be described as inferior, ventral, and either right or left upper or lower quadrants.
Rationale 3: The superior aspect would be above the waist. Ventral and dorsal surfaces include the front and back
of the body. Superior left lateral would be the left chest, or breath sounds. The stomach is on the superior plane,
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

but is generally not assessed by the nurse dorsally. The headache is in the cranial cavity. Abdominal problems
would be described as inferior, ventral, and either right or left upper or lower quadrants.
Rationale 4: The superior aspect would be above the waist. Ventral and dorsal surfaces include the front and back
of the body. Superior left lateral would be the left chest, or breath sounds. The stomach is on the superior plane,
but is generally not assessed by the nurse dorsally. The headache is in the cranial cavity. Abdominal problems
would be described as inferior, ventral, and either right or left upper or lower quadrants.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: List common terms for identifying body parts and locations during examination.
Question 12
Type: MCSA
While examining a 14-year-old for spinal curvature, the nurse notes a slight curving of the upper spine, and
documents it as which of the following?
1. Slight curve to the right noted in the superior thoracic spine.
2. Spinal column shows a slight curve to the right.
3. Spinal column appears to curve to the right.
4. Scoliosis noted on the spinal column.
Correct Answer: 1
Rationale 1: Documenting a slight curve to the right on the superior thoracic spine tells others exactly where the
curve was noted. Stating that the spinal column shows a curve, or appears to curve, does not adequately describe
the location of the defect. Scoliosis is a medical diagnosis, and nurses do not diagnose.
Rationale 2: Documenting a slight curve to the right on the superior thoracic spine tells others exactly where the
curve was noted. Stating that the spinal column shows a curve, or appears to curve, does not adequately describe
the location of the defect. Scoliosis is a medical diagnosis, and nurses do not diagnose.
Rationale 3: Documenting a slight curve to the right on the superior thoracic spine tells others exactly where the
curve was noted. Stating that the spinal column shows a curve, or appears to curve, does not adequately describe
the location of the defect. Scoliosis is a medical diagnosis, and nurses do not diagnose.
Rationale 4: Documenting a slight curve to the right on the superior thoracic spine tells others exactly where the
curve was noted. Stating that the spinal column shows a curve, or appears to curve, does not adequately describe
the location of the defect. Scoliosis is a medical diagnosis, and nurses do not diagnose.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: List common terms for identifying body parts and locations during examination.
Question 13
Type: MCSA
Which of the following could the nurse perform in order to reduce the anxiety of a 70-year-old client about to
undergo a physical examination?
1. Ask the client to identify herself.
2. Give the client a gown to wear.
3. Tell the client what will be done throughout the examination.
4. Tells the client that there is no need to be nervous.
Correct Answer: 3
Rationale 1: Helping the client to understand exactly what will happen reduces anxiety caused by fear of the
unknown. The nurse would introduce himself to the client rather than making the client identify herself. While
helping the client into a gown might be a necessary part of the preparation process, it could increase the client's
level of anxiety. Telling the client there is no reason to be nervous negates the client's feelings, and is a barrier to a
therapeutic relationship.
Rationale 2: Helping the client to understand exactly what will happen reduces anxiety caused by fear of the
unknown. The nurse would introduce himself to the client rather than making the client identify herself. While
helping the client into a gown might be a necessary part of the preparation process, it could increase the client's
level of anxiety. Telling the client there is no reason to be nervous negates the client's feelings, and is a barrier to a
therapeutic relationship.
Rationale 3: Helping the client to understand exactly what will happen reduces anxiety caused by fear of the
unknown. The nurse would introduce himself to the client rather than making the client identify herself. While
helping the client into a gown might be a necessary part of the preparation process, it could increase the client's
level of anxiety. Telling the client there is no reason to be nervous negates the client's feelings, and is a barrier to a
therapeutic relationship.
Rationale 4: Helping the client to understand exactly what will happen reduces anxiety caused by fear of the
unknown. The nurse would introduce himself to the client rather than making the client identify herself. While
helping the client into a gown might be a necessary part of the preparation process, it could increase the client's
level of anxiety. Telling the client there is no reason to be nervous negates the client's feelings, and is a barrier to a
therapeutic relationship.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Describe nursing care of the client undergoing an assessment.
Question 14
Type: MCSA
The nurse measures the client's blood pressure, and the client inquires what the reading was. The nurse does
which of the following?
1. Calls the physician to ask if the blood pressure can be shared with the client.
2. Tell the client that the doctor will be with him shortly to discuss his BP.
3. Tell the client that the blood pressure reading must be interpreted by the physician.
4. Tell the client what the reading was and its meaning, using it as a teaching opportunity.
Correct Answer: 4
Rationale 1: The client has the right to know what his blood pressure reading is, and the nurse can use it as a
teaching opportunity if it is high, discussing the need to take prescribed medications or reduce salt intake in the
diet. The physician does not need to be consulted for permission to share information with the client, and it is not
necessary for the physician to interpret the results. There is no reason to make the client wait to ask the physician
for the BP results, as the nurse is competent to provide that information.
Rationale 2: The client has the right to know what his blood pressure reading is, and the nurse can use it as a
teaching opportunity if it is high, discussing the need to take prescribed medications or reduce salt intake in the
diet. The physician does not need to be consulted for permission to share information with the client, and it is not
necessary for the physician to interpret the results. There is no reason to make the client wait to ask the physician
for the BP results, as the nurse is competent to provide that information.
Rationale 3: The client has the right to know what his blood pressure reading is, and the nurse can use it as a
teaching opportunity if it is high, discussing the need to take prescribed medications or reduce salt intake in the
diet. The physician does not need to be consulted for permission to share information with the client, and it is not
necessary for the physician to interpret the results. There is no reason to make the client wait to ask the physician
for the BP results, as the nurse is competent to provide that information.
Rationale 4: The client has the right to know what his blood pressure reading is, and the nurse can use it as a
teaching opportunity if it is high, discussing the need to take prescribed medications or reduce salt intake in the
diet. The physician does not need to be consulted for permission to share information with the client, and it is not
necessary for the physician to interpret the results. There is no reason to make the client wait to ask the physician
for the BP results, as the nurse is competent to provide that information.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Describe nursing care of the client undergoing an assessment.
Question 15
Type: MCSA
The nurse documents crackles in the lung field when which of the following is heard?
1. A low-pitched snoring sound
2. A high-pitched musical sound
3. Air passing through narrowed air passages
4. Air passing through fluid or mucus
Correct Answer: 4
Rationale 1: Air passing through fluid or mucus will sound like a crackling noise. Air passing through narrowed
passages is termed rhonchi, described as a low-pitched snoring sound. A high-pitched musical sound is wheezing.
Rationale 2: Air passing through fluid or mucus will sound like a crackling noise. Air passing through narrowed
passages is termed rhonchi, described as a low-pitched snoring sound. A high-pitched musical sound is wheezing.
Rationale 3: Air passing through fluid or mucus will sound like a crackling noise. Air passing through narrowed
passages is termed rhonchi, described as a low-pitched snoring sound. A high-pitched musical sound is wheezing.
Rationale 4: Air passing through fluid or mucus will sound like a crackling noise. Air passing through narrowed
passages is termed rhonchi, described as a low-pitched snoring sound. A high-pitched musical sound is wheezing.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify terms used in physical health assessment of the lungs.
Question 16
Type: MCSA

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

The nurse caring for a client diagnosed with pleurisy auscultates the lungs for which of the following anticipated
findings?
1. Friction rub heard in lower left anterior chest
2. Friction rub heard in dorsal upper left chest
3. Friction rub heard in middle left lobe
4. Rhonchi noted in the left bronchi
Correct Answer: 1
Rationale 1: Friction rubs most often are heard in the lower anterior lateral chest. Rhonchi can be noted in any
area of the lung, but generally are not associated with pleurisy.
Rationale 2: Friction rubs most often are heard in the lower anterior lateral chest. Rhonchi can be noted in any
area of the lung, but generally are not associated with pleurisy.
Rationale 3: Friction rubs most often are heard in the lower anterior lateral chest. Rhonchi can be noted in any
area of the lung, but generally are not associated with pleurisy.
Rationale 4: Friction rubs most often are heard in the lower anterior lateral chest. Rhonchi can be noted in any
area of the lung, but generally are not associated with pleurisy.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify terms used in physical health assessment of the lungs.
Question 17
Type: MCSA
The nurse plans to collect data on a client who has been admitted with mild respiratory distress secondary to
pulmonary edema. When planning the sequence of the assessment, the nurse would do which of the following?
1. Plan to assess the client to minimize position changes.
2. Perform the respiratory assessment first.
3. Assess from head-to-toe.
4. Begin by assessing cardiac status.
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Correct Answer: 2
Rationale 1: The priority for assessment is the respiratory system because this is the source of the client's distress.
Minimizing position changes would not be a consideration, because movement is very important for the client
with pulmonary edema in order to promote reabsorption of fluid and reduce the risk of infection. Performing a
head-to-toe or cardiac assessment would delay data collection on the priority system. The LPN/LVN would
perform a focused assessment of the respiratory system and report findings to the RN before continuing to collect
other data.
Rationale 2: The priority for assessment is the respiratory system because this is the source of the client's distress.
Minimizing position changes would not be a consideration, because movement is very important for the client
with pulmonary edema in order to promote reabsorption of fluid and reduce the risk of infection. Performing a
head-to-toe or cardiac assessment would delay data collection on the priority system. The LPN/LVN would
perform a focused assessment of the respiratory system and report findings to the RN before continuing to collect
other data.
Rationale 3: The priority for assessment is the respiratory system because this is the source of the client's distress.
Minimizing position changes would not be a consideration, because movement is very important for the client
with pulmonary edema in order to promote reabsorption of fluid and reduce the risk of infection. Performing a
head-to-toe or cardiac assessment would delay data collection on the priority system. The LPN/LVN would
perform a focused assessment of the respiratory system and report findings to the RN before continuing to collect
other data.
Rationale 4: The priority for assessment is the respiratory system because this is the source of the client's distress.
Minimizing position changes would not be a consideration, because movement is very important for the client
with pulmonary edema in order to promote reabsorption of fluid and reduce the risk of infection. Performing a
head-to-toe or cardiac assessment would delay data collection on the priority system. The LPN/LVN would
perform a focused assessment of the respiratory system and report findings to the RN before continuing to collect
other data.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Describe suggested sequencing to conduct a physical health assessment in an orderly
fashion.
Question 18
Type: MCSA
The LPN/LVN may have several responsibilities regarding the clients assessment, and it is most important to
know
1. The difference between a complete and focused assessment
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2. The scope of practice defined by the state board of nursing


3. Who can delegate to the LPN/LVN
4. The sequence of assessment
Correct Answer: 2
Rationale 1: It is important to know the difference between the types of assessment, however it is not the most
important consideration.
Rationale 2: The LPN/LVN must know and follow the scope of practice defined by the state board of nursing and
facility policy
Rationale 3: This is important, but not the most important issue
Rationale 4: The sequence of assessment is not primary in this situation.
Global Rationale:
Cognitive Level:
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 19
Type: MCMA
The complete assessment is done when the client is admitted to the healthcare facility. Information that the
LPN/LVN may be asked to collect includes:(Select all that apply)
Standard Text: Select all that apply.
1. Allergies
2. Level of ambulation
3. Nursing diagnoses
4. Head to toe assessment
5. Fall risk assessment
Correct Answer: 1,2,4,5
Rationale 1: Allergies are an important piece of data to be collected during the health history
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Rationale 2: -The level of ambulation and self care ability is importan data to collect curing the admission
assessment
Rationale 3: -Nursing diagnoses are determined by an RN
Rationale 4: -The LPN/LVN may be asked to collect data with a ful head toe assessment
Rationale 5: -A fall risk assessment is an important piece of information to collect during the admission
assessment
Global Rationale:
Cognitive Level:
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 20
Type: MCMA
The nurse uses each of the following assessments during the course of every clients care, including:(Select all
that apply)
Standard Text: Select all that apply.
1. Complete assessment
2. Focused assessment by body system
3. Focused assessment of a body part
4. Fontanel assessment
5. Pain threshold
Correct Answer: 1,2,3
Rationale 1: Rationale 2: Rationale 3: Rationale 4: Rationale 5: Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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Global Rationale:
Cognitive Level:
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 21
Type: MCSA
The LPN/LVN may have several responsibilities regarding the clients assessment, and it is most important to
know
1. The difference between a complete and focused assessment
2. The scope of practice defined by the state board of nursing
3. Who can delegate to the LPN/LVN
4. The sequence of assessment
Correct Answer: 2
Rationale 1: It is important to know the difference between the types of assessment, however it is not the most
important consideration.
Rationale 2: The LPN/LVN must know and follow the scope of practice defined by the state board of nursing and
facility policy
Rationale 3: This is important, but not the most important issue
Rationale 4: The sequence of assessment is not primary in this situation.
Global Rationale:
Cognitive Level:
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 22
Type: MCMA

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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The complete assessment is done when the client is admitted to the healthcare facility. Information that the
LPN/LVN may be asked to collect includes:(Select all that apply)
Standard Text: Select all that apply.
1. Allergies
2. Level of ambulation
3. Nursing diagnoses
4. Head to toe assessment
5. Fall risk assessment
Correct Answer: 1,2,4,5
Rationale 1: Allergies are an important piece of data to be collected during the health history
Rationale 2: -The level of ambulation and self care ability is importan data to collect curing the admission
assessment
Rationale 3: -Nursing diagnoses are determined by an RN
Rationale 4: -The LPN/LVN may be asked to collect data with a ful head toe assessment
Rationale 5: -A fall risk assessment is an important piece of information to collect during the admission
assessment
Global Rationale:
Cognitive Level:
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 23
Type: MCMA
The nurse uses each of the following assessments during the course of every clients care, including:(Select all
that apply)
Standard Text: Select all that apply.
1. Complete assessment
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2. Focused assessment by body system


3. Focused assessment of a body part
4. Fontanel assessment
5. Pain threshold
Correct Answer: 1,2,3
Rationale 1: Rationale 2: Rationale 3: Rationale 4: Rationale 5: Global Rationale:
Cognitive Level:
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 24
Type: MCMA
The LPN/LVN is performing a focused assessment on the client with a draining wound. Information that will be
collected includes:(Select all that apply)
Standard Text: Select all that apply.
1. Skin integrity
2. Odor noted
3. Vital signs
4. Intake and output
5. Symmetry of chest movements
Correct Answer: 1,2,3,4
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Rationale 1: The progress of wound healing, or lack thereof is information that needs to be obtained and
documented
Rationale 2: Odor emanating from the wound may indicate infection
Rationale 3: Vital signs are important to obtain to determine if there are systemic signs of infection
Rationale 4: If the wound is draining copious amounts of fluid, the client is at risk for fluid imbalance
Rationale 5: Symmetry of chest movements is not part of the focused assessment of the wound
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts:
Learning Outcome:
Question 25
Type: MCSA
A client who has been a resident of the long term care facility for 6 months is complaining of shortness of breath.
The nurse will perform a focused assessment that includes:
1. Auscultation of the hypogastric region
2. Clients lifestyle
3. Use of a pulse oximeter
4. Shape of pupils
Correct Answer: 3
Rationale 1: The
Rationale 2: The
Rationale 3: The
Rationale 4: The
Global Rationale:
Cognitive Level: Applying
Client Need:
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Client Need Sub:


Nursing/Integrated Concepts:
Learning Outcome:
Question 26
Type: MCSA
At the end of the shift the nurse performs a focused assessment by body system. Information that is important to
collect includes all of the following except:
1. Behavior
2. Respiratory rate
3. Level of comfort
4. Dietary habits
Correct Answer: 4
Rationale 1: Interactions with the client are important to assess for appropriateness
Rationale 2: The clients respiratory status is important to assess each shift or more often
Rationale 3: The clients comfort is important to assess and document
Rationale 4: The clients dietary habits are part of a complete health history, not a daily focused assessment
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts:
Learning Outcome:
Question 27
Type: MCMA
The nurse is performing a focused assessment of the clients gastrointestinal status. Appropriate data to collect
would include:(Select all that apply)
Standard Text: Select all that apply.
1. Bowel sounds
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2. Appetite
3. Range of motion
4. Characteristics of emesis
5. Presence of wheezing
Correct Answer: 1,2,4
Rationale 1: Auscultation of bowel sounds in all four quadrants is appropriate data to collect and document
Rationale 2: Information regarding the clients appetite and percentage of intake of meals is important
information to collect and document
Rationale 3: Range of motion is appropriate information to collect and document in the musculoskeletal
assessment
Rationale 4: The amount, , color and frequency of emesis is important data to collect and document
Rationale 5: The presence of wheezing is appropriate data to collect and document in the respiratory assessment
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts:
Learning Outcome:
Question 28
Type: MCMA
When the nurse is performing an admission physical assessment on the pediatric client who is under 30 days old,
additional data to note includes:(Select all that apply)
Standard Text: Select all that apply.
1. Shape of head
2. Presence of barrel-chested appearance
3. Asymmetric gluteal folds
4. Presence of receding gums
5. Excursion symmetry or asymmetry of chest on respiration
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Correct Answer: 1,3


Rationale 1: The shape of the infants head should only be altered by vaginal delivery for about 1 week; longer
than that may need follow up
Rationale 2: The shape of the infants head should only be altered by vaginal delivery for about 1 week; longer
than that may need follow up
Rationale 3: The shape of the infants head should only be altered by vaginal delivery for about 1 week; longer
than that may need follow up
Rationale 4: The shape of the infants head should only be altered by vaginal delivery for about 1 week; longer
than that may need follow up
Rationale 5: The shape of the infants head should only be altered by vaginal delivery for about 1 week; longer
than that may need follow up
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts:
Learning Outcome:
Question 29
Type: MCMA
The LPN/LVN is preparing to perform a focused assessment by body system. Appropriate actions include:(Select
all that apply)
Standard Text: Select all that apply.
1. Explaining the procedure
2. Instructing clients to retain urine for the procedure
3. Organizing the assessment so that several body areas can be assessed in one position
4. Providing for privacy
5. Preparing equipment
Correct Answer: 1,3,4,5
Rationale 1: Explaining the procedure will decrease client anxiety and increase the clients ability to cooperate
with the procedure
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Rationale 2: The clients should be instructed to empty their bladders prior to the examination; this facilitates
palpation of the abdomen and pubic area, and helps them feel more comfortable
Rationale 3: Several positions may be necessary for the client to assume during a physical assessment; the
clients physical condition, energy level, and age should be taken into consideration
Rationale 4: Draping the client with bed linens exposes one area at a time, providing privacy and warmth
Rationale 5: Preparing all equipment necessary for the assessment prior to beginning will make the client and
nurse more comfortable, and facilitate the procedure
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts:
Learning Outcome:
Question 30
Type: MCSA
The nursing student is preparing to perform a physical examination of the adult client. The techniques the student
will not utilize is:
1. Smelling
2. Auscultation
3. Percussion
4. Palpation
Correct Answer: 3
Rationale 1: The student will use olfactory and auditory cues, as well as visual observation
Rationale 2: The student will use olfactory and auditory cues, as well as visual observation
Rationale 3: The student will use olfactory and auditory cues, as well as visual observation
Rationale 4: The student will use olfactory and auditory cues, as well as visual observation
Global Rationale:
Cognitive Level:
Client Need:
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Client Need Sub:


Nursing/Integrated Concepts:
Learning Outcome:
Question 31
Type: MCMA
A client is admitted to the postoperative unit in the acute care hospital. The nurse gathers data using inspection,
such as
Standard Text: Select all that apply.
1. Color of the skin and mucous membranes
2. Nail bed color
3. Hair growth
4. Respiratory rate
5. Fragility of bones
Correct Answer: 1,2,3,4
Rationale 1: The color of body surfaces can be assessed using visual inspection
Rationale 2: Nail beds can be assessed by inspection
Rationale 3: Patterns of hair growth, or lack of hair can be assessed visually
Rationale 4: Respiratory rate can be determined by observing the rise and fall of the chest
Rationale 5: Fragility of bones cannot be assessed visually
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 32
Type: MCMA
The nursing student is observing the LPN/LVN performing auscultation during a physical examination. Areas of
the body for which auscultation is appropriate include:
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Standard Text: Select all that apply.


1. Heart
2. Abdomen
3. Skull
4. Neck
5. Hands
Correct Answer: 1,2,4
Rationale 1: The nurse uses a stethoscope to listen to heart sounds
Rationale 2: The nurse uses a stethoscope to listen to bowel sounds
Rationale 3: Auscultation is not used on the skull
Rationale 4: Auscultation can be used on the neck to assess carotid arteries
Rationale 5: Auscultation cannot be used on the hands
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 33
Type: MCMA
While assessing the child, the nurse uses palpation to assess:(Select all that apply)
Standard Text: Select all that apply.
1. Texture of hair
2. Temperature
3. Vibration
4. Mobility
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5. Color
Correct Answer: 1,2,3,4
Rationale 1: Texture of hair can be assessed using palpation
Rationale 2: Temperature of skin can be assessed using palpation
Rationale 3: Vibration of joints and blood vessels can be assessed using palpation
Rationale 4: Mobility of joints can be assessed using touch and palpation
Rationale 5: Color is assessed using visual inspection
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 34
Type: MCSA
Light palpation is used by the LPN/LVN to assess:(Select all that apply)
1. Distension of the bladder
2. Help the client to clear the respiratory tract
3. Mobility of organs
4. Size of organs
Correct Answer: 1
Rationale 1: The LPN/LVN uses light palpation to assess distention of the bladder or abdomen
Rationale 2: Percussion is used to help the client to clear the respiratory tract
Rationale 3: Deep palpation is used to assess mobility of organs, and is not usually done by the LPN/LVN
Rationale 4: Deep palpation is used to assess the size of organs, and is not usually done by the LPN/LVN
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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Cognitive Level: Applying


Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 35
Type: SEQ
The nurse prepares to collect data for assessment by organizing the necessary equipment, and preparing the
environment. In the focused physical assessment by body system, the nurse will follow a general order. Place the
following assessments in the most appropriate order from first intervention to last intervention.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. General appearance
Choice 2. Attitude of client
Choice 3. Level of consciousness and orientation
Choice 4. Assessing motor response
Choice 5. Inspection of skin
Choice 6. Cardiovascular assessment
Choice 7. Inspecting thorax and lungs
Choice 8. Abdominal assessment
Correct Answer: 1,2,3,4,5,6,7,8
Rationale 1: The nurse begins physical assessment with a general survey of clients appearance
Rationale 2: The nurse follows the appearance assessment with the assessment of the general attitude and
behavior of the client
Rationale 3: Following the general survey, the nurse evaluates the level of consciousness and orientation,
including the use of the Glasgow Coma Scale
Rationale 4: Following the LOC assessment, the nurse assess the clients motor responses to simple commands,
and evaluates the clients gait
Rationale 5: The assessment of the integumentary system is performed using inspection and palpation

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Rationale 6: Cardiovascular assessment follows the integumentary system, evaluating heart sounds, and
peripheral vascular system
Rationale 7: Inspection, palpation and auscultation of the thorax and lungs allows the nurse to identify deviations
from normal respiratory status
Rationale 8: Abdominal assessment is performed by first inspecting, then using auscultation, followed by
palpation
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 36
Type: MCMA
The nurse is performing a physical assessment on an elderly client. The nurse evaluates the muscular skeletal
system, understanding that the following may be normal in the geriatric client:(Select all that apply)
Standard Text: Select all that apply.
1. Elderly clients have decreased ROM
2. Elderly clients have decreased subcutaneous fat that may affect ability to stay warm
3. Vigorous assessment techniques such as hopping on one foot is appropriate
4. Evaluation of ability to carry out ADLs may indicate a deviation from normal in the musculoskeletal system
assessment
5. Warmth in one or more joints
Correct Answer: 1,4
Rationale 1: Elderly clients may have decreased ROM
Rationale 2: Elderly clients may have decreased ROM
Rationale 3: Elderly clients may have decreased ROM
Rationale 4: Elderly clients may have decreased ROM
Rationale 5: Elderly clients may have decreased ROM
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Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 37
Type: SEQ
When performing abdominal assessments, the nurse follows a specific order of examination. List the following
techniques from first to last:
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Inspection
Choice 2. Auscultation
Choice 3. Palpation
Correct Answer: 1,2,3
Rationale 1: The nurse inspects the abdomen for skin integrity, contour and symmetry
Rationale 2: The nurse then auscultates the abdomen for bowel sounds and vascular sounds
Rationale 3: Palpation is performed last, as the stimulation of the intestines may alter the bowel sounds.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 38
Type: MCSA
While performing the focused assessment of the client with a urinary tract infection, the nurse will first assess the
client for:
1. Color of urine
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2. Distended bladder
3. Continence
4. Frequency
Correct Answer: 3
Rationale 1: The nurse does not assess the color of the urine first
Rationale 2: The nurse will palpate the area above the pubic symphysis if the clients history indicates possible
urinary retention
Rationale 3: Assessing the client for continence and independent urination is the first step in the genitourinary
assessment
Rationale 4: Frequency is not the first characteristic of the genitourinary assessment that the nurse will assess
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 39
Type: SEQ
The nurse is preparing to assess the skin of a client with a history of eczema. The assessment will follow a logical
sequence. Place the following in the appropriate order
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Inspect skin color
Choice 2. Inspect uniformity of skin color
Choice 3. Inspect and describe skin lesions
Choice 4. Observe and palpate skin moisture
Choice 5. Palpate skin temperature
Choice 6. Note skin turgor
Correct Answer: 1,2,3,4,5,6
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Rationale 1: Visual inspection of skin color is step one in the integumentary assessment
Rationale 2: Visual inspection of skin color is step one in the integumentary assessment
Rationale 3: Visual inspection of skin color is step one in the integumentary assessment
Rationale 4: Visual inspection of skin color is step one in the integumentary assessment
Rationale 5: Visual inspection of skin color is step one in the integumentary assessment
Rationale 6: Visual inspection of skin color is step one in the integumentary assessment
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 40
Type: MCMA
The RN may delegate to LPNs/LVNs a variety of data-collecting tasks, including:(Select all that apply)
Standard Text: Select all that apply.
1. The focused assessment at the beginning of the shift
2. The focused assessment at the end of the shift
3. The focused assessment of a body part in relation to client complaints
4. Specific assessment of the nurseing intervention provided
5. Determination of nursing diagnosis related to assessment data
Correct Answer: 1,2,3,4
Rationale 1: NO FEEDBACK
Rationale 2: NO FEEDBACK
Rationale 3: NO FEEDBACK
Rationale 4: NO FEEDBACK
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Rationale 5: NO FEEDBACK
Global Rationale:
Cognitive Level:
Client Need:
Client Need Sub:
Nursing/Integrated Concepts:
Learning Outcome:
Question 41
Type: MCMA
Information that the LPN/LVN may collect during a complete health history includes
Standard Text: Select all that apply.
1. Vital signs
2. Dietary habits
3. Impairments
4. Medication history
5. Height
Correct Answer: 2,3,4
Rationale 1: Rationale 2: Rationale 3: Rationale 4: Rationale 5: Global Rationale:
Cognitive Level:
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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Question 42
Type: MCSA
The LPN/LVN can have several responsibilities regarding the clients assessment, and it is most important to
know:
1. The difference between a complete and focused assessment.
2. The scope of practice defined by the state board of nursing.
3. Who can delegate to the LPN/LVN.
4. The sequence of assessment.
Correct Answer: 2
Rationale 1: It is important to know the difference between the types of assessment; however, it is not the most
important consideration.
Rationale 2: The LPN/LVN must know and follow the scope of practice defined by the state board of nursing and
facility policy.
Rationale 3: This is important, but not the most important issue.
Rationale 4: The sequence of assessment is not primary in this situation.
Global Rationale:
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 43
Type: MCMA
The complete assessment is done when the client is admitted to the healthcare facility. Information that the
LPN/LVN might be asked to collect includes:
Standard Text: Select all that apply.
1. Allergies.
2. Level of ambulation.
3. Nursing diagnoses.
4. Head-to-toe assessment.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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5. Fall risk assessment.


Correct Answer: 1,2,4,5
Rationale 1: Allergies are an important piece of data to be collected during the health history.
Rationale 2: -The level of ambulation and self-care ability are important data to collect curing the admission
assessment.
Rationale 3: -Nursing diagnoses are determined by an RN.
Rationale 4: -The LPN/LVN might be asked to collect data with a full head-to-toe assessment.
Rationale 5: -A fall risk assessment is an important piece of information to collect during the admission
assessment.
Global Rationale:
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 44
Type: MCMA
The nurse uses each of the following assessments during the course of every clients care, including:
Standard Text: Select all that apply.
1. Complete assessment.
2. Focused assessment by body system.
3. Focused assessment of a body part.
4. Fontanel assessment.
5. Pain threshold.
Correct Answer: 1,2,3
Rationale 1:
Rationale 2:
Rationale 3:
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Rationale 4:
Rationale 5:
Global Rationale:
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 45
Type: MCSA
The LPN/LVN can have several responsibilities regarding the clients assessment, and it is most important to
know:
1. The difference between a complete and focused assessment.
2. The scope of practice defined by the state board of nursing.
3. Who can delegate to the LPN/LVN.
4. The sequence of assessment.
Correct Answer: 2
Rationale 1: It is important to know the difference between the types of assessment; however, it is not the most
important consideration.
Rationale 2: The LPN/LVN must know and follow the scope of practice defined by the state board of nursing and
facility policy.
Rationale 3: This is important, but not the most important issue.
Rationale 4: The sequence of assessment is not primary in this situation.
Global Rationale:
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 46
Type: MCMA
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The LPN/LVN is performing a focused assessment on the client with a draining wound. Information that will be
collected includes:
Standard Text: Select all that apply.
1. Skin integrity.
2. Odor noted.
3. Vital signs.
4. Intake and output.
5. Symmetry of chest movements.
Correct Answer: 1,2,3,4
Rationale 1: The progress of wound healing, or lack thereof, is information that needs to be obtained and
documented.
Rationale 2: Odor emanating from the wound could indicate infection.
Rationale 3: Vital signs are important to obtain to determine whether there are systemic signs of infection.
Rationale 4: If the wound is draining copious amounts of fluid, the client is at risk for fluid imbalance.
Rationale 5: Symmetry of chest movements is not part of the focused assessment of the wound.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 47
Type: MCSA
A client who has been a resident of the long-term care facility for 6 months is complaining of shortness of breath.
The nurse will perform a focused assessment that includes:
1. Auscultation of the hypogastric region.
2. Clients lifestyle.
3. Use of a pulse oximeter.
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4. Shape of pupils.
Correct Answer: 3
Rationale 1:
Rationale 2:
Rationale 3:
Rationale 4:
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 48
Type: MCSA
At the end of the shift, the nurse performs a focused assessment by body system. Information that is important to
collect includes all of the following except:
1. Behavior.
2. Respiratory rate.
3. Level of comfort.
4. Dietary habits.
Correct Answer: 4
Rationale 1: Interactions with the client are important to assess for appropriateness.
Rationale 2: The clients respiratory status is important to assess each shift or more often.
Rationale 3: The clients comfort is important to assess and document.
Rationale 4: The clients dietary habits are part of a complete health history, not a daily focused assessment.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:


Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 49
Type: MCMA
The nurse is performing a focused assessment of the clients gastrointestinal status. Appropriate data to collect
would include:
Standard Text: Select all that apply.
1. Bowel sounds.
2. Appetite.
3. Range of motion.
4. Characteristics of emesis.
5. Presence of wheezing.
Correct Answer: 1,2,4
Rationale 1: Auscultation of bowel sounds in all four quadrants is appropriate data to collect and document.
Rationale 2: Information regarding the clients appetite and percentage of intake of meals is important
information to collect and document.
Rationale 3: Range of motion is appropriate information to collect and document in the musculoskeletal
assessment.
Rationale 4: The amount, color, and frequency of emesis are important data to collect and document.
Rationale 5: The presence of wheezing is appropriate data to collect and document in the respiratory assessment.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 50
Type: MCMA
When the nurse is performing an admission physical assessment on the pediatric client who is younger than 30
days old, additional data to note include:
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Standard Text: Select all that apply.


1. Shape of the head.
2. Presence of barrel-chested appearance.
3. Asymmetric gluteal folds.
4. Presence of receding gums.
5. Excursion symmetry or asymmetry of chest on respiration.
Correct Answer: 1,3
Rationale 1: The shape of the infants head should be altered by vaginal delivery for only about 1 week; longer
than that might need follow-up.
Rationale 2: The shape of the infants head should be altered by vaginal delivery for only about 1 week; longer
than that might need follow-up.
Rationale 3: The shape of the infants head should be altered by vaginal delivery for only about 1 week; longer
than that might need follow-up.
Rationale 4: The shape of the infants head should be altered by vaginal delivery for only about 1 week; longer
than that might need follow-up.
Rationale 5: The shape of the infants head should be altered by vaginal delivery for only about 1 week; longer
than that might need follow-up.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 51
Type: MCMA
The LPN/LVN is preparing to perform a focused assessment by body system. Appropriate actions include:
Standard Text: Select all that apply.
1. Explaining the procedure.
2. Instructing clients to retain urine for the procedure.
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3. Organizing the assessment so that several body areas can be assessed in one position.
4. Providing for privacy.
5. Preparing equipment.
Correct Answer: 1,3,4,5
Rationale 1: Explaining the procedure will decrease client anxiety and increase the clients ability to cooperate
with the procedure.
Rationale 2: The client should be instructed to empty his bladders prior to the examination; this facilitates
palpation of the abdomen and pubic area, and helps him feel more comfortable.
Rationale 3: Several positions might be necessary for the client to assume during a physical assessment; the
clients physical condition, energy level, and age should be taken into consideration.
Rationale 4: Draping the client with bed linens exposes one area at a time, providing privacy and warmth.
Rationale 5: Preparing all equipment necessary for the assessment prior to beginning will make the client and
nurse more comfortable, and facilitate the procedure.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 52
Type: MCSA
The nursing student is preparing to perform a physical examination of the adult client. The technique the student
will not utilize is:
1. Smelling.
2. Auscultation.
3. Percussion.
4. Palpation.
Correct Answer: 3
Rationale 1: The student will use olfactory and auditory cues, as well as visual observation.
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Rationale 2: The student will use olfactory and auditory cues, as well as visual observation.
Rationale 3: The student will use olfactory and auditory cues, as well as visual observation.
Rationale 4: The student will use olfactory and auditory cues, as well as visual observation.
Global Rationale:
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 53
Type: MCMA
A client is admitted to the postoperative unit in the acute care hospital. The nurse gathers data using inspection,
such as:
Standard Text: Select all that apply.
1. Color of the skin and mucous membranes.
2. Nail bed color.
3. Hair growth.
4. Respiratory rate.
5. Fragility of bones.
Correct Answer: 1,2,3,4
Rationale 1: The color of body surfaces can be assessed using visual inspection.
Rationale 2: Nail beds can be assessed by inspection.
Rationale 3: Patterns of hair growth, or lack of hair, can be assessed visually.
Rationale 4: Respiratory rate can be determined by observing the rise and fall of the chest.
Rationale 5: Fragility of bones cannot be assessed visually.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:


Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 54
Type: MCMA
The nursing student is observing the LPN/LVN performing auscultation during a physical examination. Areas of
the body for which auscultation is appropriate include the:
Standard Text: Select all that apply.
1. Heart.
2. Abdomen.
3. Skull.
4. Neck.
5. Hands.
Correct Answer: 1,2,4
Rationale 1: The nurse uses a stethoscope to listen to heart sounds.
Rationale 2: The nurse uses a stethoscope to listen to bowel sounds.
Rationale 3: Auscultation is not used on the skull.
Rationale 4: Auscultation can be used on the neck to assess carotid arteries.
Rationale 5: Auscultation cannot be used on the hands.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 55
Type: MCMA
While assessing the child, the nurse uses palpation to assess:
Standard Text: Select all that apply.
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1. Texture of hair.
2. Temperature.
3. Vibration.
4. Mobility.
5. Color.
Correct Answer: 1,2,3,4
Rationale 1: Texture of hair can be assessed using palpation.
Rationale 2: Temperature of skin can be assessed using palpation.
Rationale 3: Vibration of joints and blood vessels can be assessed using palpation.
Rationale 4: Mobility of joints can be assessed using touch and palpation.
Rationale 5: Color is assessed using visual inspection.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 56
Type: MCSA
Light palpation is used by the LPN/LVN :
1. To assess distension of the bladder.
2. To help the client to clear the respiratory tract.
3. To assess mobility of organs.
4. To assess size of organs.
Correct Answer: 1
Rationale 1: The LPN/LVN uses light palpation to assess distention of the bladder or abdomen.
Rationale 2: Percussion is used to help the client to clear the respiratory tract.
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Rationale 3: Deep palpation is used to assess mobility of organs, and is not usually done by the LPN/LVN.
Rationale 4: Deep palpation is used to assess the size of organs, and is not usually done by the LPN/LVN.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 57
Type: SEQ
The nurse prepares to collect data for assessment by organizing the necessary equipment and preparing the
environment. In the focused physical assessment by body system, the nurse will follow a general order. Place the
following assessments in the most appropriate order from first intervention to last intervention:
Standard Text: Click and drag the options below to move them up or down.
Choice 1. General appearance
Choice 2. Attitude of client
Choice 3. Level of consciousness and orientation
Choice 4. Motor response
Choice 5. Skin
Choice 6. Cardiovascular
Correct Answer: 1,2,3,4,5,6
Rationale 1: The nurse begins physical assessment with a general survey of the clients appearance.
Rationale 2: The nurse begins physical assessment with a general survey of the clients appearance.
Rationale 3: The nurse begins physical assessment with a general survey of the clients appearance.
Rationale 4: The nurse begins physical assessment with a general survey of the clients appearance.
Rationale 5: The nurse begins physical assessment with a general survey of the clients appearance.
Rationale 6: The nurse begins physical assessment with a general survey of the clients appearance.
Global Rationale:
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Cognitive Level: Applying


Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 58
Type: MCMA
The nurse is performing a physical assessment on an elderly client. The nurse evaluates the muscular skeletal
system, understanding that the following might be typical in the geriatric client:
Standard Text: Select all that apply.
1. Elderly clients have decreased ROM.
2. Elderly clients have decreased subcutaneous fat that can affect their ability to stay warm.
3. Vigorous assessment techniques such as hopping on one foot are appropriate.
4. Evaluation of the ability to carry out ADLs can indicate a deviation from normal in the musculoskeletal system
assessment.
5. Warmth in one or more joints.
Correct Answer: 1,4
Rationale 1: Elderly clients can have decreased ROM.
Rationale 2: Elderly clients can have decreased ROM.
Rationale 3: Elderly clients can have decreased ROM.
Rationale 4: Elderly clients can have decreased ROM.
Rationale 5: Elderly clients can have decreased ROM.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 59
Type: SEQ
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

When performing abdominal assessments, the nurse follows a specific order of examination. List the following
techniques from first to last:
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Inspection
Choice 2. Auscultation
Choice 3. Palpation
Correct Answer: 1,2,3
Rationale 1: The nurse inspects the abdomen for skin integrity, contour, and symmetry.
Rationale 2: The nurse then auscultates the abdomen for bowel sounds and vascular sounds.
Rationale 3: Palpation is performed last, as the stimulation of the intestines can alter the bowel sounds.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 60
Type: MCSA
While performing the focused assessment of the client with a urinary tract infection, the nurse first will assess the
client for:
1. Color of urine.
2. Distended bladder.
3. Continence.
4. Frequency.
Correct Answer: 3
Rationale 1: The nurse does not assess the color of the urine first.
Rationale 2: The nurse will palpate the area above the clients pubic symphysis if the clients history indicates
possible urinary retention.
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Rationale 3: Assessing the client for continence and independent urination is the first step in the genitourinary
assessment.
Rationale 4: Frequency is not the first characteristic of the genitourinary assessment that the nurse will assess.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 61
Type: SEQ
The nurse is preparing to assess the skin of a client with a history of eczema. The assessment will follow a logical
sequence. Place the following in the appropriate order:
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Inspect skin color.
Choice 2. Inspect uniformity of skin color.
Choice 3. Inspect and describe skin lesions.
Choice 4. Observe and palpate skin moisture.
Choice 5. Palpate skin temperature.
Choice 6. Note skin turgor.
Correct Answer: 1,2,3,4,5,6
Rationale 1: Visual inspection of skin color is step one in the integumentary assessment.
Rationale 2: Visual inspection of skin color is step one in the integumentary assessment.
Rationale 3: Visual inspection of skin color is step one in the integumentary assessment.
Rationale 4: Visual inspection of skin color is step one in the integumentary assessment.
Rationale 5: Visual inspection of skin color is step one in the integumentary assessment.
Rationale 6: Visual inspection of skin color is step one in the integumentary assessment.
Global Rationale:
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Cognitive Level: Applying


Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 62
Type: MCMA
The RN may delegate to LPNs/LVNs a variety of data-collecting tasks, including:
Standard Text: Select all that apply.
1. The focused assessment at the beginning of the shift.
2. The focused assessment at the end of the shift.
3. The focused assessment of a body part in relation to client complaints.
4. Specific assessment of the nursing intervention provided.
5. Determination of nursing diagnosis related to assessment data.
Correct Answer: 1,2,3,4
Rationale 1:
Rationale 2:
Rationale 3:
Rationale 4:
Rationale 5:
Global Rationale:
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 63
Type: MCMA
Information that the LPN/LVN may collect during a complete health history includes:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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Standard Text: Select all that apply.


1. Vital signs.
2. Dietary habits.
3. Impairments.
4. Medication history.
5. Height.
Correct Answer: 2,3,4
Rationale 1:
Rationale 2:
Rationale 3:
Rationale 4:
Rationale 5:
Global Rationale:
Cognitive Level:
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:

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