Question

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

Answer 1

Correct Answers:

Atrophy
Contracture
Kyphosis

Rationale :

🔎Inspection focuses on what you can see in body structure and posture.

💪Atrophy is visible as muscle wasting or decreased muscle bulk.

🧷Contractures appear as abnormal fixed positioning or limited joint extension at rest.

🧍Kyphosis is a visible spinal curvature change noted by observing alignment.

📌Core Message

Inspection identifies visible posture and structural changes like atrophy, contracture, and kyphosis.

Answer 2

Correct Answers:

Assess the client's ability to read a Snellen chart from a distance of 20 feet.

Rationale :

👁️A Snellen chart measures visual acuity, which relates directly to legal blindness criteria.

📏Testing at 20 feet standardizes distance so results are comparable and valid.

📝Visual acuity results provide objective support for the client’s reported vision limitation.

🏥This helps guide documentation and referrals based on measured impairment.

📌Core Message

A Snellen chart provides objective visual acuity data to support reported legal blindness.

Answer 3

Correct Answers:

Muscle tone
Pupil size
Glasgow coma scale
Cranial nerves
Level of consciousness

Rationale :

🧠A focused neuro exam targets brain function changes common in suspected stroke.

🔦Assessing pupil size checks cranial nerve function and possible increased intracranial issues.

🧾The Glasgow Coma Scale and level of consciousness track neurologic deterioration or improvement.

🧩Checking cranial nerves and muscle tone helps detect localized deficits and motor involvement.

📌Core Message

Stroke-focused checks include LOC, GCS, pupils, cranial nerves, and motor tone to detect neurologic change quickly.

Answer 4

Correct Answers:

The gallbladder is normal.

Rationale :

🫀A normal gallbladder is typically not palpable in most healthy adults.

🖐️Gallbladder palpation usually detects it only when it is enlarged or inflamed.

🧑‍⚕️Failure to palpate it is generally a normal expected finding, even with careful technique.

📋This supports documenting the assessment as nonpalpable, consistent with normal anatomy.

📌Core Message

A gallbladder is usually not palpable unless enlarged, so “not found” is often normal.

Answer 5

Correct Answers:

Asthma

Rationale :

🌬️Asthma causes bronchoconstriction, leading to expiratory wheezing and prolonged expiration.

🚨Low oxygen saturation with retractions reflects increased work of breathing from narrowed airways.

🫁Decreased breath sounds and reduced fremitus can occur with air trapping in obstructive episodes.

🏃Exercise is a common trigger for acute asthma symptoms in susceptible clients.

📌Core Message

The pattern of expiratory wheeze, air trapping, and respiratory distress fits asthma.

Answer 6

Correct Answers:

Red, swollen, painful nodule located on upper back on a school-aged boy.

Rationale :

🦠A red, swollen, painful nodule suggests possible infection such as an abscess or cellulitis.

🌡️Skin infections can worsen quickly and may require medical treatment like drainage or antibiotics.

🧼Reporting supports early intervention and reduces risk of spread to others.

📞This is more urgent than routine minor findings because it signals active inflammation.

📌Core Message

A painful, swollen, red nodule may indicate infection and should be reported promptly.

Answer 7

Correct Answers:

"What does, 'The early bird catches the worm,' mean?"

Rationale :

🧠Abstract thinking is the ability to interpret non-literal meaning and concepts.

📜Proverbs require understanding implied lessons rather than concrete facts.

🔍Explaining a proverb assesses reasoning and interpretation, not just memory.

🗣️This approach is commonly used in mental status exams to evaluate higher-level cognition.

📌Core Message

Interpreting a proverb best tests abstract thinking and higher-level reasoning.

Answer 8

Correct Answers:

Document this finding in the medical record.

Rationale :

🎨Patchy pigmentation in the mouth can be a normal variation in clients with darker skin tones.

🧾Normal variations should be documented to establish an accurate baseline.

🩺Documentation supports comparison over time if the appearance later changes.

✅This avoids unnecessary referrals when the finding matches a benign expected pattern.

📌Core Message

Patchy oral pigmentation can be normal, so documenting establishes a clear baseline.

Answer 9

Correct Answers:

Normal bowel sounds.

Rationale :

🍽️Normal peristalsis produces intermittent gurgles in each quadrant.

⏱️A pattern every 5–10 seconds is consistent with typical adult bowel activity.

🩻Presence in all quadrants supports normal distribution of intestinal movement.

📝This should be charted as normal, since the timing and character are expected.

📌Core Message

Regular gurgles heard every few seconds in all quadrants are normal bowel sounds.

Answer 10

Correct Answers:

Hematocrit changes from 36% to 32%.

Rationale :

🩸A falling hematocrit suggests a decreasing proportion of red blood cells in circulation.

📉In GI bleeding, continued blood loss commonly shows as dropping Hct/Hgb trends.

🧪Trends are key because a single value may miss ongoing loss, but downward movement signals persistence.

🏥This indicates the client may still be bleeding and needs continued monitoring and intervention.

📌Core Message

A decreasing hematocrit trend suggests ongoing blood loss, meaning the bleed is not resolved.

1 :
The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

2 :
A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

3 :
A nurse is caring for a patient.

Answer Options

4 :
While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

6 :
Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

7 :
The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

8 :
The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

9 :
While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

1 : The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

2 : A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

3 : A nurse is caring for a patient.

Answer Options

4 : While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

6 : Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

7 : The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

8 : The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

9 : While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

1 :
The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

2 :
A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

3 :
A nurse is caring for a patient.

4 :
While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

6 :
Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

7 :
The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

8 :
The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

9 :
While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?