chapter 3

Page 1
1. A client has presented to the clinic for the treatment of an ovarian cyst. Which of the
following would be most important for the nurse to do immediately before performing
this woman’s physical exam?
A) Explain the purpose of the interview to the client.
B) Construct the client’s family genogram.
C) Establish the client’s reliability as historian.
D) Collect necessary equipment essential to the exam.
2. A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test
and pelvic examination. The nurse is implementing actions to help reduce a client’s
anxiety during the physical exam. Which of the following would be most appropriate?
A) Ensuring client’s privacy by providing an examination gown
B) Providing a comfortable, warm room temperature
C) Arranging exam equipment on a bedside tray table
D) Explaining why standard precautions are being used
3. A nurse is admitting a new client to the subacute medical unit and is completing a
comprehensive assessment. The nurse is appropriately applying standard precautions by
performing which of the following actions?
A) Performing hand hygiene between examinations of each body part
B) Discarding in the trash can the safety pin that was used to assess sensory perception
C) Wearing gloves to palpate the tongue and buccal membranes
D) Wearing a gown, gloves, and mask during the physical exam
4. The nurse is using a Wood’s light for a client who has complaints of itching, burning,
and peeling of the skin between his toes. The nurse is assessing for what etiology of the
client’s symptoms?
A) Parasitic infection
B) Fungal infection
C) Bacterial infection
D) Allergic reaction
5. A nurse has gathered the necessary equipment for the physical assessment of an adult
client. For which of the following assessments would it be most appropriate for a nurse
to use a centimeter-scale ruler for measurement?
A) Mid-arm circumference
B) Client’s height
C) Skin lesion size
D) Pupillary size
Page 2
6. The nurse is preparing to assess an older adult client’s near vision. Which of the
following pieces of equipment would be most appropriate for the nurse to use?
A) Newspaper
B) Snellen chart
C) Ophthalmoscope
D) Penlight
7. A nurse practitioner is performing a comprehensive physical examination of a 51-yearold
man. After performing a digital-rectal exam for prostate enlargement and
tenderness, the nurse checks the fecal material on the gloved finger for the presence of
which of the following?
A) Parasites
B) Blood
C) Bacteria
D) Fungus
8. The nurse is examining an older adult client and using a goniometer. Which of the
following would the nurse be assessing?
A) Extremity edema
B) Joint flexion/extension
C) Two-point discrimination
D) Vibratory sensation
9. A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She
says ìAbsolutely not! There’s no way I’ll let you do that to me!î Which response by the
nurse would be most appropriate?
A) Explain the importance of the pelvic exam and Pap smear, but respect the client’s
wishes and omit the exam.
B) Tell the client that this is the only way she can be checked for cancer.
C) Ask the client if she would prefer another practitioner to perform the exam.
D) Proceed with the pelvic exam and document the client’s protests in the health
record.
10. The nurse is preparing to perform a physical examination on a female client who has
been transferred to the medical unit from the emergency department. The nurse should
begin the collection of objective data with which of the following examinations?
A) Head and neck examination
B) Palpation of lymph nodes
C) Breast examination
D) Vital signs
Page 3
11. The nurse is to collect a throat culture from a client who has signs and symptoms of a
respiratory infection, including frequent, productive coughing. The nurse demonstrates
the best adherence to standard precautions by using which of the following pieces of
equipment?
A) Eye goggles
B) Face mask
C) Cover gown
D) Face shield
12. The nurse is preparing to perform the physical examination of an older adult client who
will begin rehabilitation from an ischemic stroke. Which of the following actions would
be most appropriate?
A) Omit intrusive parts of the exam.
B) Try to minimize position changes.
C) Allow client to remain dressed.
D) Dim the room light to ensure privacy.
13. The nurse is preparing to assess the peripheral pulses of a client. The nurse should place
the client in which position?
A) Sitting upright
B) Supine
C) Sims position
D) Prone
14. When assessing the temperature of the feet of an older client with diabetes, the nurse
would use which part of the hand to obtain the most accurate assessment data?
A) Finger pad surface
B) Palmar hand surface
C) Dorsal hand surface
D) Ulnar hand surface
15. A client has a documented history of hepatomegaly (liver enlargement), and the nurse
recognizes the need to perform deep palpation during the physical assessment. The
nurse should perform which of the following actions?
A) Use one hand and depress the skin 1 centimeter.
B) Use the dominant hand to depress the skin one-half to three-quarters of an inch.
C) Use both hands to depress the skin one-half of an inch.
D) Use both hands to depress the skin 1 to 2 inches.
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16. The emergency department (ED) nurse is assessing for kidney tenderness in a client
who has presented with complaints of dysuria and back pain. What assessment
technique should the nurse utilize?
A) Deep palpation
B) Indirect percussion
C) Moderate palpation
D) Blunt percussion
17. In the course of performing a client’s physical assessment, the nurse has changed from
using the diaphragm of the stethoscope to using the bell. The nurse is most likely
assessing which of the following?
A) Heart sounds
B) Bowel sounds
C) Breath sounds
D) Femoral pulses
18. An instructor is teaching a student about the proper use of a stethoscope. The instructor
determines the need for additional teaching when the student states which of the
following?
A) ìPlastic tubing should be longer than 3 feet.î
B) ìThe bell is used after using the diaphragm.î
C) ìWhen using the bell, push on it lightly.î
D) ìA diaphragm picks up low-pitched sounds.î
19. A nurse is preparing to perform the physical examination of an adult client who has
presented to the clinic for the first time. Which of the following statements should guide
the nurse’s use of a stethoscope during this phase of assessment?
A) Auscultation can be performed through clothing.
B) The diaphragm should be held firmly against the body part.
C) The bell of the stethoscope can best detect bowel sounds.
D) Use of the bell is reserved for advanced practice nurses.
20. A nurse is appraising a colleague’s assessment technique as part of a continuing
education initiative. The nurse demonstrates the proper technique for light palpation by
performing which of the following actions?
A) Depressing the skin 1 to 2 centimeters with the dominant hand
B) Feeling the surface structures using a circular motion
C) Placing the nondominant hand on top of the dominant hand
D) Using one hand to apply pressure and the other hand to feel the structure
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21. The nurse is preparing to examine an older adult client. Which of the following would
be most appropriate for the nurse to do during the examination?
A) Complete the examination as quickly as possible.
B) Speak clearly and slowly when explaining a procedure.
C) Begin the examination with auscultation instead of inspection.
D) Maintain the supine position for each part of the examination.
22. The nurse assists a client into the dorsal recumbent position. Assessment of which area
is contraindicated when the client is in this position?
A) Chest
B) Head
C) Peripheral pulses
D) Abdomen
23. The nurse is gathering the necessary equipment preparatory to examining a client’s ears.
The nurse will be checking bone and air conduction of sound. Which of the following
should the nurse obtain?
A) Penlight
B) Tongue depressor
C) Tuning fork
D) Otoscope
24. The nurse is evaluating the setting prior to beginning a client’s physical examination.
The nurse should confirm the presence of which of the following? Select all that apply.
A) Adequate lighting
B) Cool room temperature
C) Quiet surroundings
D) Soft chair or table
E) Table for equipment
F) Door or curtain
25. The nurse is using her fingerpads to palpate a client’s body part during the physical
examination. Which of the following would the nurse best be able to detect?
A) Temperature
B) Vibrations
C) Pulses
D) Fremitus
Page 6
26. A nurse is reviewing the four basic physical examination techniques and their sequence
prior to receiving a new client from postanesthetic recovery. The nurse should plan to
perform which technique first?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
27. The nurse is percussing the area over the client’s lungs and hears a loud, low-pitched,
hollow sound. The nurse documents this finding as which of the following?
A) Flatness
B) Resonance
C) Tympany
D) Dullness
28. A 20-year-old female client has presented to the clinic, and the nurse is preparing to
perform a comprehensive assessment. The client states, ìI’d really like to have my mom
in the room. That’s okay, isn’t it?î How should the nurse best respond to the client’s
request?
A) ìOf course. There’s a chair in the exam room where she can sit.î
B) ìThat’s no problem. I’ll just have to get you to sign a privacy waiver first.î
C) ìThat’s fine, but be aware that some of the examinations might be embarrassing for
you or her.î
D) ìIt’s best to undergo the examination alone in order to make sure I get accurate
data, but if you really want her present, we can do that.î
29. The nurse is inspecting the dominant hand of an older adult client and notes the
presence of irregularly shaped brown lesions on the dorsal surface of the client’s hand.
What action should the nurse perform next?
A) Obtain a tissue sample for pathology
B) Compare the appearance of the client’s other hand
C) Palpate the lesions for tenderness and warmth
D) Perform health promotion teaching about sun protection
30. A young man has presented to the clinic with a 2-week history of head congestion,
fever, and malaise. What assessment technique should the nurse utilize to assess for
sinus tenderness?
A) Light palpation
B) Deep palpation
C) Direct percussion
D) Blunt percussion
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Page 8
Answer Key
1. D
2. A
3. C
4. B
5. C
6. A
7. B
8. B
9. A
10. D
11. D
12. B
13. B
14. C
15. D
16. D
17. A
18. C
19. B
20. B
21. B
22. D
23. C
24. A, C, E, F
25. C
26. A
27. B
28. A
29. B
30. C
 
chapter 5
Page 1
1. A nurse has completed a comprehensive assessment of a client and has begun the
process of data analysis. Data analysis should allow the nurse to produce which of the
following direct results?
A) Outcomes evaluation
B) Nursing diagnoses
C) Holistic interventions
D) An interdisciplinary plan of care
2. A new nursing graduate recently made an oversight during the analysis of a client’s
assessment data that resulted in a postoperative complication. What characteristic of
data analysis makes it a challenging aspect of nursing practice?
A) Abnormal data must be identified.
B) It requires the prior identification of nursing diagnoses.
C) It requires sophisticated diagnostic reasoning skills.
D) Conclusions must be clearly and accurately documented.
3. A hospital nurse has identified a need to improve her critical thinking skills in an effort
to improve client care. The nurse should identify which of the following characteristics
of critical thinking?
A) It is an innate skill that some individuals possess and which others do not.
B) It does not include past experiences.
C) It is based primarily on getting correct and timely information.
D) It involves reflections on thoughts before reaching conclusions.
4. The emergency department has collected extensive data from a client who has presented
with a new onset of severe abdominal pain. What nursing action should the nurse
perform before proceeding with data analysis?
A) Validate the collected data.
B) Formulate a nursing diagnosis.
C) Make inferences about the data.
D) Identify the client’s strengths.
5. A nurse has completed a client’s initial assessment and is preparing to identify abnormal
data and the client’s strengths. Successful completion of this phase of the nursing
process most requires which of the following?
A) Knowledge of anatomy and physiology
B) Awareness of the client’s medical prognosis
C) Inferences about the client
D) Knowledge about the referral process
6. A nurse is planning a client’s care following the completion of an initial assessment.
When formulating a risk nursing diagnosis, which piece of data would be most useful?
A) The client has an elevated white blood cell count.
B) The client is 66 years of age.
C) The client has pain in her joints, especially in the morning.
D) The client is separated from her usual social supports.
7. During the assessment interview, the client made numerous statements that suggested
his life generally exists in a state of harmony and balance. This fact would most likely
prompt the nurse to identify which of the following?
A) Actual nursing diagnosis
B) Risk nursing diagnosis
C) Collaborative problem
D) Health promotion diagnosis
8. A nurse is caring for a client who has been admitted with an infected venous ulcer. The
nurse determines that the client will need medical interventions as well as nursing
interventions. The nurse would identify which of the following?
A) Actual nursing diagnosis
B) Referral
C) Risk nursing diagnosis
D) Collaborative problem
9. A nurse has assessed a client and identified data that are associated with the diagnoses
of Impaired Physical Mobility and Activity Intolerance. How can the nurse best
determine which nursing diagnosis is most applicable to the client?
A) Document preliminary conclusions.
B) Identify abnormal data.
C) Check the defining characteristics of the diagnoses.
D) Test the nursing diagnoses clinically.
10. A nurse is analyzing the assessment data of a client who has been admitted with
exacerbation of heart failure. The nurse has determined that the cue clusters meet the
defining characteristics of specific nursing diagnoses. Which of the following would the
nurse do next?
A) Explain the client’s problems to the client and his or her family.
B) Verify it with the client and with other health care professionals.
C) Validate the diagnosis with the physician.
D) Work with the client to begin planning interventions.
Page 3
11. A nurse’s data analysis has led to the formulation of a risk nursing diagnosis. Which of
the following best demonstrates accurate documentation of a risk nursing diagnosis?
A) Risk for fatigue related to increased job demands, as manifested by feelings of
exhaustion and frequent naps
B) Risk for infection, as manifested by lack of client knowledge of wound care
C) Risk for violence related to history of overt, aggressive acts
D) Risk for altered respiratory function related to environmental allergens, as
manifested by asthma
12. A nurse is preparing to document conclusions after analyzing data, and he or she
includes information about related factors and manifestations. The nurse is formulating
which of the following?
A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Collaborative problem
D) Problem for referral
13. A nurse is applying the diagnostic reasoning process in the care of a client. What is the
correct sequence of the steps that the nurse should perform?
A) Check for defining characteristics.
B) Draw inferences.
C) Propose possible nursing diagnoses.
D) Identify abnormal data and strengths.
E) Cluster data.
14. The nurse has collected objective and subjective data during the assessment of a client
who has been admitted for the treatment of an exacerbation of chronic obstructive
pulmonary disease (COPD). During the current phase of the diagnostic reasoning
process, the nurse is writing down thoughts about each cue cluster of data that was
collected. The nurse is involved in which step of the diagnostic reasoning process?
A) Step One: Identify Abnormal Data and Strengths
B) Step Two: Cluster Data
C) Step Three: Draw Inferences
D) Step Four: Propose Possible Nursing Diagnoses
15. A nurse is determining whether the data for a client support a potential nursing
diagnosis. The nurse is most likely engaged in which step in the diagnostic reasoning
process?
A) Step Three: Draw Inferences
B) Step Four: Propose Possible Nursing Diagnoses
C) Step Five: Check for Defining Characteristics
D) Step Six: Confirm or Rule Out Diagnoses
16. A nurse is applying the diagnostic reasoning process in the care of a client with a
number of comorbidities. Which of the following descriptions best characterizes Step
Two, Clustering Data?
A) Hypothesizing of any potentially applicable health promotion diagnoses, risk
diagnoses, and actual diagnoses
B) Documentation of all professional judgments along with any data that support
those judgments
C) Examining identified abnormal findings and strengths for cues that are related
D) Evaluation of both subjective and objective data to identify strengths and abnormal
findings
17. An experienced nurse is teaching a recently graduated colleague about common pitfalls
encountered in the diagnostic reasoning process. The experienced nurse should identify
a need for further teaching if the new graduate identifies which of the following as a
pitfall?
A) View of things as either right or wrong
B) Overemphasis on details
C) Inclusion of valid data
D) Clustering of unrelated cues
18. A nurse on a busy acute medical unit asks a clinical educator for suggestions on how to
best develop expertise in using diagnostic reasoning skills to arrive at correct
conclusions. Which of the following statements would be most appropriate?
A) “You need to cluster the data more rapidly.”
B) “This skill comes with accumulating experience.”
C) “Try to be more efficient in documenting the data.”
D) “This is a skill that only comes with an advanced practice designation.”
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19. A nurse has identified a goal of developing his critical thinking skills. In order to
facilitate this goal, what action should the nurse prioritize?
A) Applying quick decision-making
B) Seeking new experiences
C) Maintaining an open mind
D) Maintaining a stable and static knowledge base
20. After teaching a group of students about the second phase of the nursing process, the
instructor determines that additional teaching is needed when the students identify
which of the following as a component?
A) Organizing data
B) Clustering data
C) Formulating a medical diagnosis
D) Generating hypotheses
21. An experienced medical-surgical nurse has identified critical thinking as an integral
component of diagnostic reasoning. How can the relationship between these two
concepts be best described?
A) Critical thinking is the practical application of diagnostic reasoning skills.
B) Critical thinking and diagnostic reasoning are synonymous.
C) Critical thinking is the foundation of the process of diagnostic reasoning.
D) Critical thinking is the domain of the novice nurse, whereas diagnostic reasoning is
present in experts.
22. During an educational inservice, nursing have been encouraged to conduct a
self-appraisal of their critical thinking skills. Which of the following questions can best
guide this appraisal?
A) “Do I tend to make errors in my nursing practice?”
B) “Do I get good feedback from clients and their families?”
C) “Am I open to the fact that I may not be right?”
D) “Am I a resource to my colleagues during a crisis?”
23. A nurse has admitted a client to the medical unit who has just been diagnosed with
endocarditis secondary to IV drug use. The nurse has completed the collection of
objective and subjective data. What question should guide the next step in the nurse’s
data analysis?
A) “What are this client’s strengths?”
B) “What is this client’s prognosis?”
C) “Why does this client use opioids?”
D) “What are this client’s hopes for the future?”
24. The nurse is attempting to cluster the data that she collected during the initial
assessment of an older adult client. The nurse notes that the client had a swollen left
knee and complained of “a bit of soreness” in the joint, but the nurse does not have
enough data to support a nursing diagnosis of Impaired Physical Mobility. What should
the nurse do next?
A) Document a suspected nursing diagnosis of Impaired Physical Mobility.
B) Assess the client further for evidence of reduced mobility and decreased range of
motion.
C) Make a referral to the physical therapist.
D) Plan interventions that will conservatively manage the client’s joint dysfunction.
25. A nurse has been clustering the data that he collected during the initial assessment of a
frail elderly client. When making inferences about the data clusters, the nurse is unsure
whether to associate a cluster of data with a nursing diagnosis or with a collaborative
problem. What question may best guide the nurse’s decision?
A) “Can an unlicensed care provider meet this person’s needs?”
B) “Is this problem acute or is it chronic?”
C) “Can this issue be addressed on an outpatient basis?”
D) “Does this issue require medical intervention?”
26. A nurse is providing care for a client who has longstanding type 2 diabetes. In recent
days, the client’s blood glucose levels have been higher and more volatile than usual.
After drawing this inference, the nurse should take what action?
A) Make appropriate referrals
B) Assess the client more frequently
C) Document the medical diagnosis of hyperglycemia
D) Beginning collecting subjective data
27. The nurse’s assessment of a client with a decreased level of consciousness reveals that
the client is incontinent of urine. During the process of data analysis, the nurse would be
justified in identifying what risk nursing diagnosis?
A) Risk for Injury related to urinary incontinence
B) Risk for Infection related to urinary incontinence
C) Risk for Bowel Incontinence related to urinary incontinence
D) Risk for Impaired Skin Integrity related to urinary incontinence
Page 7
28. A nurse has selected several nursing diagnoses in the process of data analysis of a client
with poorly controlled type 1 diabetes. One of these diagnoses is Ineffective Health
Maintenance related to infrequent blood glucose monitoring as manifested by elevated
HgA1C. The nurse recognizes the need to corroborate this diagnosis with the client.
How should the nurse best do this?
A) “I think you have a nursing diagnosis of Ineffective Health Maintenance.”
B) “Would you agree that there’s room for improvement in your routines around blood
sugar monitoring?”
C) “After assessing you, I believe that you’re not maintaining your health effectively,
specifically around your diabetes.”
D) “How do you think that you could better maintain your health?”
29. Data analysis of assessment data from a client who presented to the emergency
department has resulted in the nurse making a syndrome nursing diagnosis. What is a
primary characteristic of this type of diagnosis?
A) The client’s health problem cannot be conveyed using standard nursing language.
B) The client’s current signs and symptoms are the result of a longstanding health
problem.
C) The client has health problems that will require multidisciplinary care.
D) The client has a number of nursing diagnoses that typically occur together.
30. A nurse has collecting extensive data during a client assessment and is performing the
first step in the process of data analysis. Successful completion of this step requires the
nurse to do which of the following?
A) Differentiate between expected findings and abnormal findings.
B) Validate nursing diagnoses with the client and the client’s family.
C) Integrate the client’s medical diagnosis with nursing diagnoses.
D) Perform health promotion education.
Answer Key
1. B
2. C
3. D
4. A
5. A
6. D
7. D
8. D
9. C
10. B
11. C
12. B
13. D, E, B, C, A
14. C
15. D
16. C
17. C
18. B
19. C
20. C
21. C
22. C
23. A
24. B
25. D
26. A
27. D
28. B
29. D
30. A