When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is:

To allow for the client to focus on the illness

To allow for the client to spend more time with the nurse

To allow the nurse more time to know the client

To develop a plan with interventions that promote health

Answer and Explanation

The Correct Answer is D

A. To allow for the client to focus on the illness: Accurate and complete information is crucial for developing a proper care plan but not directly related to the client’s focus on their illness.

B. To allow for the client to spend more time with the nurse: Accurate information helps in forming a plan but does not necessarily impact the amount of time spent with the nurse.

C. To allow the nurse more time to know the client: While knowing the client is important, the primary reason for accurate information is to develop effective interventions.

D. To develop a plan with interventions that promote health: Accurate and complete assessment information is essential for developing a comprehensive care plan and interventions that address the client’s health needs.

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Correct Answer is B

Explanation

A. Anterior chest: While the anterior chest examination is important, axillary palpation is more specific to the breast area.

B. Breasts: Palpation of the axillae is part of the breast examination to check for lymph nodes or masses.

C. Heart: The heart is assessed through auscultation and palpation of the chest, not the axillae.

D. Neck: The neck examination does not typically involve palpation of the axillae.

A. Use tangential lighting. B. Assist the client to a standing position. C. Use perpendicular lighting. D. Focus a penlight on the client's chest.

Correct Answer is C

Explanation

A. Use tangential lighting: Tangential lighting is not typically used for assessing heart impulses; it is more useful for examining surface characteristics of the skin.

B. Assist the client to a standing position: The client should be in a supine or semi-recumbent position for accurate inspection of apical heart impulses, not standing.

C. Use perpendicular lighting: Perpendicular lighting is crucial for accurately visualizing apical heart impulses, as it helps to clearly observe the movement of the heart against the chest wall.

D. Focus a penlight on the client's chest: While a penlight can be used in physical assessments, perpendicular lighting is more effective for clearly seeing the apical heart impulses.

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When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse would palpate the axillae during examination of which area?

Correct Answer is B

Explanation

The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Correct Answer is C

Explanation

A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?

Cranial nerves involved in eye movements are:

Which type of assessment includes a health history and physical assessment?

When performing a head-to-toe assessment, during which part would the nurse evaluate cranial nerve (CN) IX, X, and XII?

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

While inspecting the external eye of a client, the nurse notes that the client's right eyelid droops. Which term would the nurse use to document this finding?

The nurse is asking the client about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason?

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of