Online Practice Test 30

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 30 > NCLEX® Review Date/Time Submitted: July 17, 2012 at 2:00 PM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		Which exam technique is being used when the nurse touches the client's abdomen to examine the size of the liver? Your Answer: Palpation
		Objective: Explain the four methods used in physical examination. Rationale: Touching signifies palpation. Inspection is looking. Percussion is tapping. Auscultation is listening. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		In a client with long-term emphysema, the nurse might expect to see which condition when inspecting the nails? Your Answer: Clubbing
		Objective: Explain the significance of selected physical findings. Rationale: Clubbing is a condition where the nailbed is at least 180 degrees, often caused by lack of oxygen, such as in emphysema. Koilonychia is an abnormality where the nail curves upward from the nailbed, and is often seen in clients with iron-deficiency anemia. Paronychia is the technical term for "ingrown nail." A slow blanch test (greater than 2-3 seconds) may indicate circulatory problems. Nursing Process: Diagnosis Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		A client is diagnosed with a conduction hearing loss. What might the nurse indicate to the client could be a reason for this loss? Your Answer: There has been damage to the inner ear. Correct Answer: An ear infection has torn the tympanic membrane.
		Objective: Explain the significance of selected physical findings. Rationale: A conduction hearing loss is often caused by a tear in the tympanic membrane. A sensorineural hearing loss results from damage to the inner ear, the auditory nerve, or the hearing center in the brain. Nursing Process: Implementation Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		How would the nurse document a high-pitched musical sound that was auscultated during expiration?  Your Answer: Rhonchi Correct Answer: Wheeze
		Objective: Explain the significance of selected physical findings. Rationale: A high-pitched musical sound should be documented as a wheeze. Crackles (referred to as rales or crepitations) are fine, short crackling sounds. Rhonchi are continuous, low-pitched gurgling sounds. A friction rub is a superficial grating. Nursing Process: Diagnosis Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
5.		A client begins to tremor when he holds a coffee cup. What is the correct term to use when the nurse documents this event? Your Answer: An intention tremor
		Objective: Discuss variations in examination techniques appropriate for clients of different ages. Rationale: An intention tremor becomes apparent when someone attempts to do something voluntary. A resting tremor diminishes with activity. A fasciculation is an abnormal shortening of a bundle of muscle fibers. A tremor is an involuntary trembling. Nursing Process: Diagnosis Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		A client has a 5 on the Glasgow Coma Scale. When assessing this client, the nurse would expect what level of consciousness? Your Answer: Comatose
		Objective: Explain the significance of selected physical findings. Rationale: A score of 7 or less indicates a comatose client. Above that are varying degrees of consciousness. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		A nurse has a client close her eyes, and the nurse places a paper clip in the client's palm. The client correctly identifies the object. What test did the nurse perform? Your Answer: Stereognosis
		Objective: Identify the steps in selected examination procedures. Rationale: Stereognosis is the act of recognizing objects by touching and manipulating them. Extinction is failure to perceive touch on one side of the body when both sides are touched simultaneously. One- and two-point discrimination entail the ability to sense if one or two areas of the skin, respectively, are being stimulated by pressure. Paresthesia is an abnormal sensation, such as burning or pain. Nursing Process: Evaluation Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		What evidence most likely told the nurse a client had a negative Romberg test? Your Answer: Maintains an upright posture and foot stance
		Objective: Identify expected outcomes of health assessment. Rationale: A negative Romberg test would be indicated when a client was able to maintain an upright posture and foot stance with minimal swaying. A positive Romberg would show a client who couldn't maintain foot stance, moved the feet apart to maintain stance, and had increased swaying. Nursing Process: Diagnosis Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		What are the methods used for physical examination? (Select all that apply.) Your Answer: Palpation Percussion Ausculation Inspection
		Objective: Explain the four methods used in physical examination. Rationale: Four primary techniques are used on the physical examination: inspection, palpation, percussion, and auscultation. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		Which cranial nerves are assessed with the eyes and vision? (Select all that apply.) Your Answer: II III IV Correct Answers: II III IV V VI
		Objective: Identify the steps in selected examination procedures. Rationale: Cranial nerves II, III, IV, V, and VI (ophthalmic branch) are assessed with the eyes and vision. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection. Objective: Identify the steps in selected examination procedures. Rationale: Cranial nerves II, III, IV, V, and VI (ophthalmic branch) are assessed with the eyes and vision. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.