These are the EXACT RN Health Assessment (BSN 246/ASN 241) questions from nursing exams. Verified answers guarantee your success. Join thousands who passed using our materials.
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A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming today. To assist normal range of motion (ROM) of the client's shoulder, which assessment techniques should the nurse ask the client to perform?
Alternate both index fingers to tough the tip of nose accurately.
Extend arms up to 180 degrees besides the ears.
Extend arms straight out and hold without drifting.
Hold arms up at 90 degree while arms are pushed downward
The correct answer is B. Extend arms up to 180 degrees besides the ears.
Extend arms up to 180 degrees beside the ears: This action assesses the shoulder’s flexion and abduction range of motion (ROM). The ability to raise both arms to this degree indicates normal shoulder mobility. This movement is particularly important for swimming, as it requires significant shoulder flexibility and strength. Testing this ROM helps determine if the client has any limitation in shoulder movement, which could be contributing to their discomfort.
Why the other options are wrong:
A. Alternate both index fingers to touch the tip of the nose accurately: This action is used to assess coordination and proprioception (such as in cerebellar function tests) rather than the shoulder’s ROM. It’s not relevant for evaluating shoulder range of motion.
C. Extend arms straight out and hold without drifting: This action assesses muscle endurance and stability of the shoulders, but it does not specifically test the range of motion. While it evaluates strength and control, it does not provide direct information about the movement capabilities of the shoulder joint.
D. Hold arms up at 90 degrees while arms are pushed downward: This maneuver is typically used to assess for impingement syndrome or rotator cuff injuries (e.g., with the "empty can" test). It doesn’t directly evaluate the range of motion but instead tests for pain or weakness when the arms are pushed down, which may indicate specific shoulder problems rather than overall ROM.
Summary:
To assess the normal range of motion (ROM) of the shoulder, the nurse should ask the client to extend arms up to 180 degrees beside the ears. This tests for flexibility and mobility in the shoulder joint, which is relevant to the client’s swimming-related discomfort. Other options either test for muscle strength or coordination, not ROM.
A 9-year-old child typically loses which of the following teeth?
central incisor
second molar
lateral incisor
cuspid
Correct Answer: Cuspid
Children typically lose their primary (baby) teeth in a predictable order from around age 6 to 12. The cuspids (canines) are usually lost around ages 9 to 12. Since the question asks about a 9-year-old child, cuspids are a reasonable choice. The upper canines are typically lost between 10-12 years old, while the lower canines are lost between 9-12 years old. Since the child in the question is 9 years old, they may be starting to lose their cuspid teeth, making this a correct answer.
Why the Other Options are Incorrect
Central Incisor
These are usually lost first, around 6-7 years old. By age 9, the child has likely already lost both their upper and lower central incisors.
Second Molar
Second molars are lost last, usually between 10-12 years old. A 9-year-old typically still has their second molars intact.
Lateral Incisor
Lateral incisors are lost around 7-8 years old, right after the central incisors. A 9-year-old child would have already lost them in most cases.
Summary:
The cuspid (canine) is typically lost between ages 9-12, making it the most appropriate answer for a 9-year-old child.
During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is:
just changing positions.
more comfortable in this position.
tired and needs a break from the interview.
uncomfortable talking about his son's treatment.
Correct Answer: D) uncomfortable talking about his son's treatment.
When a person shifts to a closed body posture, such as crossing their arms and legs, it often indicates that they may feel defensive, anxious, or uncomfortable. In this case, the parent’s change in posture while discussing their child’s treatment suggests discomfort with the topic. The parent was initially sitting in an open posture, which usually signals openness and engagement, but the shift to a closed posture likely reflects emotional discomfort or reluctance to discuss the treatment.
Why the Other Options Are Wrong:
A) Just changing positions:
Although people can change positions for comfort, the specific change to a closed posture (arms and legs crossed) often has a psychological component indicating discomfort, not just a random change in seating
B) More comfortable in this position:
A closed posture is generally not associated with comfort. While some people may cross their arms for physical comfort, this specific body language often reflects emotional discomfort, particularly in a conversation about something personal or difficult, such as a child's treatment.
C) Tired and needs a break from the interview:
While fatigue could cause a person to change positions, it would be more likely that the person would shift to a more relaxed posture (such as slumping or reclining) rather than adopting a closed posture, which is typically a signal of emotional discomfort.
Summary:
When the parent crosses their arms and legs during a discussion about their child's treatment, it is likely an indication of discomfort or unease with the subject matter. This nonverbal cue suggests that the parent may feel defensive or hesitant about discussing the treatment, signaling the need for the nurse to approach the topic with sensitivity.
The school nurse is approached by a mother who explains that her kindergarten child is constantly scratching the perianal area and that the area is irritated. The PN understands that she should instruct the mother to obtain a rectal specimen by a tape test and that the mother should obtain the specimen when?
After bathing.
When the child is put to bed.
In the morning, when the child awakens.
After toileting.
Correct Answer: In the morning, when the child awakens.
The tape test is used to diagnose pinworm infection (Enterobius vermicularis), a common parasitic infection in young children. Female pinworms lay their eggs around the anus at night, leading to intense perianal itching. For accurate results, the tape test should be performed:
Immediately upon waking up, before the child bathes or uses the toilet.
A piece of clear adhesive tape is pressed against the perianal area to collect eggs.
The tape is then placed on a glass slide and taken to a healthcare provider for examination under a microscope.
Why the Other Options Are Incorrect:
After bathing
Bathing can wash away the pinworm eggs, leading to false-negative results.
When the child is put to bed
The eggs are laid at night, but the best time to collect them is after they have accumulated overnight, which is in the morning before the child moves too much.
After toileting
Wiping or cleaning after using the toilet can remove eggs, reducing the accuracy of the test.
Summary:
To diagnose pinworms effectively, the tape test should be performed in the morning, immediately after the child wakes up, before bathing or toileting. This ensures the best chance of collecting pinworm eggs for diagnosis.
The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse to complete a focused assessment?
Ask the client how long she has experienced discomfort related to hemorrhoids.
Place the client in a standing position, leaning over the exam bed for inspection.
Determine if the client uses any over-the-counter preparation for hemorrhoids.
Position client in left lateral position to inspect perianal area for fissures or sacs.
The correct answer is D. Position client in left lateral position to inspect perianal area for fissures or sacs.
Option D is correct because the left lateral position (lying on the left side with knees bent) is the most appropriate position for a focused assessment of the perianal area. This position allows the nurse to better inspect and palpate the perianal area for signs of hemorrhoids, fissures, or other abnormalities like abscesses or sac-like structures, providing a thorough and accurate assessment.
Why the other options are incorrect:
Option A: "Ask the client how long she has experienced discomfort related to hemorrhoids."
While this is an important part of the health history, it is not the most effective intervention for conducting a focused assessment at this moment. The nurse needs to first perform an examination to visually inspect the area before further questioning.
Option B: "Place the client in a standing position, leaning over the exam bed for inspection."
The standing position is not the best for inspecting the perianal area. The left lateral position (or sometimes the lithotomy position) provides better visibility and easier access for examining hemorrhoids and other conditions in the perianal region.
Option C: "Determine if the client uses any over-the-counter preparation for hemorrhoids."
While it's important to ask about treatments, this is more relevant after completing the physical exam. The priority is first inspecting the perianal area to assess the severity of the hemorrhoids or any other issues.
Summary:
The best approach for a focused assessment of the perianal area is to position the client in the left lateral position (Option D), allowing the nurse to clearly inspect for hemorrhoids, fissures, or other complications.
The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus:
is caused by moisture in the alveoli."
indicates that there is air in the subcutaneous tissues."
is caused by sounds generated from the larynx."
reflects the blood flow through the pulmonary arteries."
Correct Answer: C) is caused by sounds generated from the larynx.
Tactile fremitus is the palpable vibration felt on the chest wall when a patient speaks. The vibrations, or fremitus, are generated by sound waves produced in the larynx (voice box) and transmitted through the bronchi and lungs to the chest wall. When a patient speaks, especially with certain sounds like "99" or "blue moon," the vibrations travel through the air in the lungs and are felt on the chest. The nurse feels these vibrations by placing their hands on the patient's chest while they speak.
Why the Other Options Are Wrong:
A) is caused by moisture in the alveoli:
Moisture in the alveoli (such as in pneumonia or pulmonary edema) may lead to abnormal lung sounds, but it does not directly cause tactile fremitus. Tactile fremitus is caused by vibrations from sound, not moisture in the lungs.
B) indicates that there is air in the subcutaneous tissues:
Air in the subcutaneous tissues would indicate a subcutaneous emphysema, which is a different condition that might be detected through palpation. This is not related to tactile fremitus, which involves vibrations caused by sound waves in the lungs.
D) reflects the blood flow through the pulmonary arteries:
Blood flow through the pulmonary arteries does not directly affect tactile fremitus. Fremitus reflects the transmission of sound vibrations through the lungs and chest wall, not blood flow.
Summary:
Tactile fremitus is a palpable vibration caused by sound waves generated by the larynx. The nurse should feel these vibrations on the chest wall while the patient speaks, and this is an important part of the physical exam to assess lung and airway conditions.
A client who uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first?
Withhold medication and report symptoms and vital signs to healthcare provider.
Give PRN medication for nausea and vomiting and evaluate client in 30 minutes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is scheduled.
Correct Answer: A) Withhold medication and report symptoms and vital signs to healthcare provider.
Ipratropium is an anticholinergic medication used to treat chronic obstructive pulmonary disease (COPD) and asthma. While it is effective in opening the airways, it can cause side effects due to its anticholinergic properties, such as nausea, blurred vision, headaches, and insomnia. Nausea, blurred vision, headaches, and insomnia are symptoms of an adverse reaction to the medication. These may indicate anticholinergic toxicity or an allergic reaction. The first step when a client reports these symptoms is to withhold the medication and notify the healthcare provider (HCP). This ensures the client is properly assessed and avoids any further complications related to the medication.
Why the Other Options Are Incorrect:
Give PRN medication for nausea and vomiting and evaluate client in 30 minutes:
While the client is experiencing nausea, this approach does not address the potential adverse reaction to the medication. The RN needs to first withhold the ipratropium and notify the healthcare provider, as the symptoms could be indicative of a more serious reaction that requires further assessment and intervention.
Reassure client that the ipratropium given will alleviate the symptoms:
This is not appropriate because the client is experiencing adverse side effects. It is essential to acknowledge the symptoms and address the possibility of a medication reaction. Reassuring the client without taking action could delay appropriate treatment.
Delay administration of ipratropium until next maintenance medication is scheduled:
This does not adequately address the current symptoms. Withholding the medication is appropriate, but the RN must first report the symptoms to the healthcare provider for further guidance.
Summary:
When a client reports symptoms such as nausea, blurred vision, headaches, and insomnia after using ipratropium, the first action the RN should take is to withhold the medication and notify the healthcare provider. This ensures the client is properly evaluated and appropriate action is taken regarding the possible adverse reaction.
What is the best thing that a nurse can say to a patient scheduled for cataract surgery who is concerned that the physician works on the correct eye?
You are wearing an ID bracelet that will let the doctor know who he is working on.
When you are wheeled into the surgical area you will be asked what your name and room number are.
The doctor will have a complete record of your case history and surgical plan when he goes in to perform the cataract surgery.
You will be wearing an ID bracelet and the nurse will ask you which eye is scheduled to be worked on. If this matches what she has in her records then she will put an X over the correct eye with a permanent marker.
Correct Answer: "You will be wearing an ID bracelet and the nurse will ask you which eye is scheduled to be worked on. If this matches what she has in her records, then she will put an X over the correct eye with a permanent marker."
Marking the surgical site is a standard safety protocol to prevent wrong-site surgery. The nurse confirms the patient's identity and surgical site with both the patient and medical records before marking the correct eye. This practice aligns with The Joint Commission's Universal Protocol, which helps ensure patient safety.
Why the Other Options Are Incorrect:
"You are wearing an ID bracelet that will let the doctor know who he is working on."
While an ID bracelet helps confirm patient identity, it does not specify the surgical site, which is critical in procedures like cataract surgery.
"When you are wheeled into the surgical area, you will be asked what your name and room number are."
Confirming name and room number helps verify patient identity but does not confirm the surgical site, which is the main concern.
"The doctor will have a complete record of your case history and surgical plan when he goes in to perform the cataract surgery."
While the surgical plan provides details, relying only on records without patient confirmation and site marking increases the risk of error.
Summary:
Patient safety in surgery requires multiple verification steps, including patient confirmation and marking the surgical site. The best response reassures the patient by explaining that both the nurse and medical records will confirm the correct eye, and the site will be marked with a permanent marker to prevent errors.
While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perineal area and anus. Which findings indicates a normal appearance of the anus?
Increased pigmentation and coarse skin.
Flap of tissue at sphincter.
Hypotonic tone of the anal sphincter.
Dimpled area above anus.
The correct answer is A. Increased pigmentation and coarse skin.
Increased pigmentation and coarse skin: It is normal for the anus to have increased pigmentation, especially in individuals with darker skin tones. The skin in this area is often coarse and may have a darker hue, which is typical of the perianal area. These characteristics are within normal limits and do not suggest any pathology.
Why the other options are wrong:
B. Flap of tissue at sphincter: A flap of tissue at the anal sphincter could indicate a skin tag or a hemorrhoid, which may be benign but should be assessed further. This is not considered a normal finding and could suggest a past or current issue with hemorrhoids.
C. Hypotonic tone of the anal sphincter: The anal sphincter should have a normal tone. Hypotonic tone (reduced muscle tone) could suggest issues such as nerve damage or neurological impairment, which is not a normal finding and may require further investigation.
D. Dimpled area above anus: A dimpled area above the anus could suggest an abnormality, such as a pilonidal cyst or a fistula, both of which are medical conditions requiring further evaluation. This is not a typical, normal finding.
Summary:
A normal appearance of the anus includes increased pigmentation and coarse skin, which is typical for this area. Other findings, like a flap of tissue or a dimpled area, may indicate a pathological condition that requires further assessment.
During an abdominal assessment, the nurse would consider which of these findings as normal?
The presence of a bruit in the femoral area
A tympanic percussion note in the umbilical region
A palpable spleen between the ninth and eleventh ribs in the left midaxillary line
A dull percussion note in the left upper quadrant at the midclavicular line
Correct Answer: B) A tympanic percussion note in the umbilical region
Tympany is the normal percussion sound heard over the stomach and intestines due to the presence of air in the digestive tract. The umbilical region is typically where tympany is expected, as it contains a large portion of the intestines. This sound indicates that there is air in the stomach or intestines, which is a normal finding.
Why the Other Options Are Incorrect
A) The presence of a bruit in the femoral area:
A bruit is an abnormal sound that occurs due to turbulent blood flow, often due to arterial narrowing or aneurysm. In the femoral area, a bruit would suggest a vascular abnormality, such as an aneurysm or stenosis, and is not normal.
C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line:
The spleen is usually not palpable in a healthy individual. If it is palpated, it may indicate splenomegaly, which can be due to various conditions such as infection, liver disease, or blood disorders. A palpable spleen is abnormal and suggests pathology.
D) A dull percussion note in the left upper quadrant at the midclavicular line:
A dull percussion note in the left upper quadrant typically indicates the presence of solid organs, such as the stomach or spleen. While dullness over the spleen may be normal if it is within the appropriate anatomical location, a significant area of dullness, especially if it extends beyond normal boundaries, could indicate splenomegaly or other pathology. Therefore, it is not necessarily a normal finding in every case.
Summary:
A tympanic percussion note in the umbilical region (Option B) is considered normal, as it reflects the presence of air in the intestines. The other options suggest findings that are either abnormal or indicative of pathology, such as a bruit, a palpable spleen, or unusual dullness over the spleen.
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