Question

Client reports pain in the right wrist with tingling in the fingers.

Answer 1

Correct Answers

Assess for psoas sign [ Non-essential ]
Perform the Lasègue test [ Non-essential ]
Perform McMurray test [ Non-essential ]
Assess for Rovsing sign [ Non-essential ]
Observe for the flick signal [ Indicated ]
Perform the Tinel sign test [ Indicated ]
Perform the Phalen test [ Indicated ]

Rationale :

✋Wrist pain, finger tingling, weakness, and dropping objects suggest carpal tunnel syndrome caused by median-nerve compression.

⚡A positive Tinel sign reproduces tingling when the median nerve is tapped at the wrist.

🙏The Phalen test reproduces symptoms when the wrists are flexed together, while the flick signal involves shaking the hand to relieve symptoms.

🦵The psoas, Lasègue, McMurray, and Rovsing tests assess abdominal, spinal, or knee conditions unrelated to carpal tunnel syndrome.

📌Core Message:

The flick signal, Tinel test, and Phalen test are appropriate assessments for suspected carpal tunnel syndrome.

Answer 2

Correct Answers:

Poor skin turgor
Thinning hair
Decreased elasticity

Rationale :

👵Aging reduces collagen, elastin, and subcutaneous tissue, causing decreased skin elasticity.

💧Older skin demonstrates poor turgor and can remain tented longer after being pinched.

💇Hair commonly becomes thinner because hair follicles decrease in number and activity.

🛡️These changes increase susceptibility to dryness, bruising, tearing, and pressure injuries.

📌Core Message:

Expected age-related findings include poor turgor, decreased elasticity, dryness, and thinning hair.

Answer 3

Correct Answers:

Client is walking with a tripod cane.
Client has a limp.
Client is alert and oriented x4.

Rationale :

👀Objective data consist of observable or measurable findings obtained during assessment.

🦯The nurse can directly observe the client walking with a tripod cane.

🚶A limp is also visible during gait assessment.

🧠Orientation can be objectively assessed by asking the client questions about person, place, time, and situation.

📌Core Message:

Objective findings are directly observed or measured, whereas pain and dizziness reported by the client are subjective.

Answer 4

Correct Answers:

The nurse advises the client that the lesion should be further evaluated as soon as possible and should initiate a referral.

Rationale :

⚠️A dark lesion with elevation and asymmetrical borders has concerning features of malignant melanoma.

🔍Suspicious lesions are evaluated using the ABCDE criteria: asymmetry, border irregularity, color variation, diameter, and evolution.

🩺Prompt dermatological examination and possible biopsy are necessary for diagnosis.

⏱️Early identification and treatment significantly improve melanoma outcomes.

📌Core Message:

An asymmetric, irregular, dark, and elevated lesion requires prompt referral for evaluation and possible biopsy.

Answer 5

Correct Answers:

Hold and gently pull the pinna of the ear downward and out.

Rationale :

👶In infants and children younger than approximately 3 years, the ear canal is shorter and angled differently than in adults.

👂Pulling the pinna downward and outward helps straighten the external auditory canal.

🔦The otoscope should be inserted gently while the examiner braces the hand against the infant’s head.

🛡️This technique improves visualization while reducing injury from sudden movement.

📌Core Message:

Straighten an infant’s ear canal by gently pulling the pinna downward and outward before otoscopic examination.

Answer 6

Correct Answers:

The client does not remember the details of the accident

Rationale :

🧠Amnesia following a motor vehicle accident can indicate a concussion or traumatic brain injury.

⚠️Changes in memory require immediate neurological assessment because intracranial injury can worsen rapidly.

👀The nurse should assess level of consciousness, pupils, orientation, motor responses, and other neurological changes.

🩻The client may require urgent neuroimaging and ongoing observation.

📌Core Message:

Memory loss after trauma is a neurological warning sign requiring immediate evaluation for traumatic brain injury.

Answer 7

Correct Answers:

Take the blood pressure several minutes after the client has entered the room.

Rationale :

⏱️The client should rest quietly for approximately 5 minutes before blood pressure measurement.

❤️Recent walking, anxiety, talking, caffeine, or exertion can temporarily elevate the reading.

🪑The client should sit with the back supported, feet flat, legs uncrossed, and arm supported at heart level.

📏Correct preparation and cuff sizing improve measurement accuracy.

📌Core Message:

Accurate blood-pressure measurement requires several minutes of rest, correct positioning, and an appropriately sized cuff.

Answer 8

Correct Answers:

Right upper quadrant

Rationale :

🫀Most of the liver lies beneath the right lower ribs in the right upper quadrant.

🥁Percussion moves from areas of lung resonance and intestinal tympany toward liver dullness.

📏The upper and lower borders of dullness can be used to estimate liver span.

⚠️Mononucleosis can cause hepatomegaly, so assessment should be performed gently.

📌Core Message:

Liver dullness is assessed primarily in the right upper quadrant along the right midclavicular line.

Answer 9

Correct Answers:

"Please call for assistance when getting out of bed."

Rationale :

📉The systolic blood pressure decreased by 20 mm Hg after standing, meeting the criterion for orthostatic hypotension.

💫Orthostatic hypotension can cause dizziness, syncope, and falls.

🛡️The immediate nursing priority is preventing injury by assisting the client with position changes and ambulation.

🩺The nurse should also reassess symptoms, review medications, evaluate hydration, and notify the provider as appropriate.

📌Core Message:

A 20-mm Hg postural drop in systolic pressure indicates orthostatic hypotension and requires fall precautions.

Answer 10

Correct Answers:

"Does anything make the pain worse?"

Rationale :

⚡Provocation identifies activities, positions, movements, or factors that worsen pain.

🗣️Asking what makes the pain worse directly assesses this element of the PQRST pain framework.

🔎The nurse should also ask what relieves the pain.

📋The remaining PQRST components include quality, region or radiation, severity, and timing.

📌Core Message:

Pain provocation is assessed by asking what activities, movements, or circumstances make the pain worse.

Assessment test	Indicated	Non-essential
Assess for psoas sign
Perform the Lasègue test
Perform McMurray test
Assess for Rovsing sign
Observe for the flick signal
Perform the Tinel sign test
Perform the Phalen test

W7 NR304 CJE Health Assessment Benchmark 2642

No.

1 :
Client reports pain in the right wrist with tingling in the fingers.

4/9 1045

Correct Answers

2 :
A nurse assesses the skin integrity of an older adult. Which finding will the nurse document as an expected finding? Select all that apply.

3 :
The nurse performs an intake interview for a new client. The client is alert and oriented to time, person, and place, has a limp, walks with a tripod cane, and complains of feeling dizzy and having an earache for two days. Which would the nurse identify as objective data? Select all that apply.

4 :
On examining the skin of a 30-year-old lifeguard, the nurse notes a dark black lesion that is elevated and has asymmetrical borders. Which is the nurse's priority action?

5 :
The nurse examines the ear of a 1-month-old infant with an otoscope. What technique should the nurse use?

6 :
30-year-old client was in a motor vehicle accident and is admitted to the emergency department. Which assessment finding is most concerning?

7 :
The nurse prepares to take a blood pressure reading on a client who just arrived at the clinic. What action will the nurse take to obtain the most accurate blood pressure reading?

8 :
During a physical assessment, the nurse percusses the abdomen of a client with Mononucleosis for liver dullness. Where should the nurse percuss?

9 :
The nurse takes an older adult client's vital signs and obtains a blood pressure reading of 130/70 mmHg while the client is in the supine position and 110/65 mmHg when the client is standing. Which response by the nurse is most appropriate?

10 :
A client arrives at the emergency department, gripping their lower leg. Which question is a priority for the nurse to ask to assess pain provocation?

W7 NR304 CJE Health Assessment Benchmark 2642

No.

1 : Client reports pain in the right wrist with tingling in the fingers.

4/9 1045

Correct Answers

2 : A nurse assesses the skin integrity of an older adult. Which finding will the nurse document as an expected finding? Select all that apply.

3 : The nurse performs an intake interview for a new client. The client is alert and oriented to time, person, and place, has a limp, walks with a tripod cane, and complains of feeling dizzy and having an earache for two days. Which would the nurse identify as objective data? Select all that apply.

4 : On examining the skin of a 30-year-old lifeguard, the nurse notes a dark black lesion that is elevated and has asymmetrical borders. Which is the nurse's priority action?

5 : The nurse examines the ear of a 1-month-old infant with an otoscope. What technique should the nurse use?

6 : 30-year-old client was in a motor vehicle accident and is admitted to the emergency department. Which assessment finding is most concerning?

7 : The nurse prepares to take a blood pressure reading on a client who just arrived at the clinic. What action will the nurse take to obtain the most accurate blood pressure reading?

8 : During a physical assessment, the nurse percusses the abdomen of a client with Mononucleosis for liver dullness. Where should the nurse percuss?

9 : The nurse takes an older adult client's vital signs and obtains a blood pressure reading of 130/70 mmHg while the client is in the supine position and 110/65 mmHg when the client is standing. Which response by the nurse is most appropriate?

10 : A client arrives at the emergency department, gripping their lower leg. Which question is a priority for the nurse to ask to assess pain provocation?

1 :
Client reports pain in the right wrist with tingling in the fingers.

2 :
A nurse assesses the skin integrity of an older adult. Which finding will the nurse document as an expected finding? Select all that apply.

3 :
The nurse performs an intake interview for a new client. The client is alert and oriented to time, person, and place, has a limp, walks with a tripod cane, and complains of feeling dizzy and having an earache for two days. Which would the nurse identify as objective data? Select all that apply.

4 :
On examining the skin of a 30-year-old lifeguard, the nurse notes a dark black lesion that is elevated and has asymmetrical borders. Which is the nurse's priority action?

5 :
The nurse examines the ear of a 1-month-old infant with an otoscope. What technique should the nurse use?

6 :
30-year-old client was in a motor vehicle accident and is admitted to the emergency department. Which assessment finding is most concerning?

7 :
The nurse prepares to take a blood pressure reading on a client who just arrived at the clinic. What action will the nurse take to obtain the most accurate blood pressure reading?

8 :
During a physical assessment, the nurse percusses the abdomen of a client with Mononucleosis for liver dullness. Where should the nurse percuss?

9 :
The nurse takes an older adult client's vital signs and obtains a blood pressure reading of 130/70 mmHg while the client is in the supine position and 110/65 mmHg when the client is standing. Which response by the nurse is most appropriate?

10 :
A client arrives at the emergency department, gripping their lower leg. Which question is a priority for the nurse to ask to assess pain provocation?