Concepts wk3 NCLEX practice.docx - Week 3 Assessment A...

Week 3 Assessment
A nurse determines that a client has 20/40 vision. Which statement about this client’s vision is
true?
a) the client can read the entire vision chart at a distance of 40'
b) the client can read from a distance of 20' what a person with normal vision can read at 40'
c) the client can read the vision chart from a distance of 20' with the right eye and from 40' with
the left eye
d) the client can read at a distance of 30' what a person can read at a distance of 40'
B) the client can read from a distance of 20' what a person with normal vision can read at 40'
the smaller the denominator the worse the vision
the numerator is always 20, the distance in feet between the chart and person
the denominator indicates what distance normal vision can read the chart
When assessing a client’s abdomen which finding should the nurse report as abnormal
a) dullness over the liver
b) bowel sounds occurring every 10 seconds
c) shifting dullness over the abdomen
d) vascular sound over the renal arteries
c) shifting dullness over the abdomen would indicate ascites which is abnormal
dullness over the liver, bowel sounds every 10 seconds and vascular sounds over the renal
arteries are all normal sounds in the abdomen
A nurse is assessing a 47-year-old client who has come to the clinic for his annual physical. One
of the first physical signs of aging is
a) having more frequent aches and pains
b) failing eyesight, especially close vision
c) increasing loss of muscle tone
d) accepting limitations while developing assets
b) failing eyesight, especially close vision is one of the first signs of aging in middle life
more frequent aches and pains occur around age 65
loss of muscle tone increases around age 80
accepting limitations while developing assets occurs around age 31-45
A nurse is assessing a client’s pulse. Which pulse feature should the nurse document?
a) timing in the cycle
b) amplitude
c) pitch
d) intensity
B) amplitude
(ARR)
Amplitude, Rate, Rhythm
When auscultating a client’s abdomen, a nurse detects high pitched gurgles over the lower
Right quadrant. Based on this finding, the nurse suspects
a) decreased bowel motility
b) increased bowel motility
c) nothing abnormal
d) abdominal cramping

c) nothing abnormal
high pitch gurgles are normal findings
While performing an abdominal assessment a nurse should follow which examination sequence
a) inspection, auscultation, percussion, palpation
b) inspection, auscultation, palpation, percussion
c) inspection, percussion, palpation, auscultation
d) inspection, palpation, percussion, auscultation
a) inspection, auscultation, percussion, palpation
all other sequencing would be inspection, palpation, percussion and then auscultation
A nurse prepares to perform an otoscopic examination on an adult. For proper visualization the
nurse should position the client’s ear by pulling the:
a) lobule down and forward
b) auricle up and back
c) auricle up and forward